Special guest blog from Kristina Rak, PharmD, BCACP, BC-ADM, CDE, Assistant Professor, Ferris State University
Every January, it is exciting to see what is going to change in the ADA’s Clinical Practice Recommendations. With this new year, one of the largest changes was relaxing the blood pressure goal in select patients with diabetes. The new treatment goals are: people with hypertension and diabetes should be treated to a systolic blood pressure of <140 mmHg and diastolic blood pressure <80 mmHg. The guidelines go on to state that lower systolic targets, such as <130 mmHg, may be appropriate for certain individuals, such as younger patients if it can be achieved without undue treatment burden (Diabetes Care, 2013). The lower systolic goal was not meant to “downplay the importance of treating hypertension in patients with diabetes,” but rather highlight the large concern of adverse effects from medication in helping patients achieve a systolic pressure of <130 (Diabetes Care, 2013). If patients are currently controlled to previous treatment goals of <130/80 and not experiencing adverse effects or “treatment burden,” there is nothing stating that continuing current treatment is inappropriate.
This change was made based on existing trial data and a new meta-analysis. The ACCORD trial compared a systolic goal of <120 mmHg in an intensive treatment arm to a systolic goal of 130-140 mmHg in a standard treatment arm (New England Journal of Medicine, 2010). Patients in the intensive treatment arm were on an average of 3.4 medications versus 2.1 medications in the standard treatment arm, but there was no significant difference in the primary endpoint of nonfatal myocardial infarction nonfatal stroke, or cardiovascular death. There were a reduced number of strokes, but an average of 89 patients would need to be treated with an intensive blood pressure goal to prevent one additional stroke over five years. Of concern was an increased risk of serious adverse events, primarily hypotension, bradycardia, arrhythmia, and hyperkalemia. Serious adverse events were defined as being life-threatening, causing permanent disability, or requiring hospitalization (New England Journal of Medicine, 2010).
The meta-analysis looked at five studies comparing pre-specified blood pressure targets. Intensive blood pressure was defined as no higher than 130/80 mmHg and standard blood pressure was defined as no higher than (140 to 160)/(85 to 100) mmHg. Of the five trials, the ACCORD trial was the only trial targeting systolic blood pressure the others targeted diastolic blood pressure, showing the small amount of literature available. The meta-analysis supported the results of the ACCORD trial (Archives of Internal Medicine, 2012). Based on these data, the ADA decided to change their blood pressure goals to <140/80 for most patients with a more stringent goal of <130/80 for those patients who can achieve this lower goal without increasing the treatment burden and the development of serious adverse events.