Hypertension and diabetes

Over the past few weeks, you have been able to read about hypertension – high blood pressure. There is no doubt that for everyone, proper control of blood pressure is key to preventing heart attack and stroke.  For people with hypertension and diabetes, many clinical research trials have demonstrated that the target blood pressure needs to be lower than the general population’s target to make sure of the best possible outcomes.  To reinforce, the target blood pressure is 130/80 for those with diabetes. For most otherwise healthy people, the target blood pressure is 140/90.

So what makes diabetes different?  Well we understand that people living with diabetes are already at a higher risk of heart attack and stroke because of the damage from high glucose levels. This risk is even higher when their blood pressure is elevated.  We do everything we can to help people with diabetes protect against heart disease and stroke, so we are more aggressive in managing blood pressure.

Many health care professionals think that blood pressure is the easiest part of risk reduction in diabetes.  Medications have changed drastically over the last 25 years.  Often the start of treatment is reducing fluid load by increasing urine production, maybe with medications that slow the heart and help it pump more effectively, and by using medication that relaxes the walls of the arteries so that the heart is not pumping as hard to get the blood flowing. 

The most significant advance in managing blood pressure in the past 25 years was the introduction of medications that target more specific areas of the kidneys.  The classes of medications that work on receptors of the kidney include angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs). These drugs have proved to be very exciting.  They not only reduce blood pressure but also help protect the kidney from diabetes related damage.  Both drugs have shown the ability to reduce the protein loss from the kidney in people with early diabetes kidney disease – an added bonus.  These medications have also been studied to determine if they can aid in protecting the other vessels in the body -  specifically the heart vessels to prevent heart disease.  Large clinical studies all demonstrated that the risk was reduced.

The newest class of drugs working within the kidney system are the direct renin inhibitors.  While not around as long, the thought was that they too would show similar benefits for people with diabetes.

But here is where it becomes interesting: if one medication working in the kidney is helpful, another one working at a slightly different area should add more benefit, right?  This is where most of the research in diabetes, high blood pressure and risk reduction has been conducted in the last 5 years. 

Unexpectedly, the results were not what were anticipated.  The major studies in which these drugs were studied being used together determined that this strategy did not help patients. In fact, it may have actually placed them at an increased risk.

So what does this mean for people with diabetes? We are back to the basics – we continue to use ACE inhibitors and the class of ARBs for the benefit of blood pressure lowering, kidney protection and heart protection but we will not see these medications used together except under very closely supervised care.  The newest class of medication, RAS, will continue to be used to help with treatment of high blood pressure.

So sometimes, more is not better and we are fortunate that research has been done to make sure treatments are safe.  Over the past few years, your loved one may have had changes made to their blood pressure medications.  Hopefully this will help you to understand why. 

How we lower blood pressure is as important as achieving the treatment targets.  Medications used safely in addition to lifestyle changes can get people to goal.