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Blood Pressure Control for Patients with Diabetes

Apr 15, 2014

The buzz in family medicine or other outpatient practices is “what is the desired blood pressure goal for a patient with diabetes?” As an academician, I am teaching my current student pharmacists about the new hypertension guidelines. However, there seems to be confusion with what goals are set by the specific guidelines. As an end result, there are three different blood pressure goals for patients with diabetes. Practitioners have been waiting for updated guidelines, particularly the anticipated Joint National Committee (JNC) VIII guidelines; this set of guidelines was published in late 2013 and specifically address other patient populations and new blood pressure goals. For this blog, I wanted to focus on the differences between the guidelines in desired blood pressure and recommended treatment.

Blood Pressure Goals
In 2007, the American Heart Association (AHA) released blood pressure guidelines for the management of ischemic heart disease (IHD).  Within these guidelines, the desired blood pressure goal for a patient with diabetes was less than 130 / 80 mm Hg.  In late 2013, the new JNC-VIII guidelines updated its blood pressure goal to support a goal less than 140 / 90 mm Hg for a patient with diabetes.  The American Diabetes Association (ADA) has released the 2014 standards for medical care in diabetes.  This set of guidelines has not changed their recommendations for the desired blood pressure.  The blood pressure goal is less than 140 / 80 mm Hg.  However, a goal of 130 / 80 mm Hg may be determined for a younger individual to prevent stroke.

Treatment Options
Within the AHA and ADA guidelines, angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) are recommended for the management of blood pressure for a patient with diabetes.  In clinical practice, ACE inhibitors are generally started as first-line therapy, but ARBs are available if a patient has a contraindication or intolerance to an ACE inhibitor.  Within the new JNC-VIII guidelines, there are some similarities or differences in the treatment options. Along with ACE inhibitors and ARBs, thiazide-type diuretic or calcium channel blocker can also be used as first-line therapy in a patient with diabetes.  For certain individuals, a thiazide-type diuretic or calcium channel blocker may have additional benefits over the other two classes.  For example, thiazide-type diuretic and calcium channel blocker work better in an African-American individual, as well as lower the stroke risk.

Guidelines Blood Pressure Goals Treatment Options
AHA (2007)
Circulation
2007;115:2761
 < 130 / 80 mm Hg 1. ACE inhibitor or ARB
2. Thiazide diuretic
3. BB or CCB
ADA (2014);37:S14.
Diabetes Care. 2014
 < 140 / 90 mm Hg  1. ACE inhibitor or ARB
JNC-VIII (2013)
JAMA 2013; doi:10.1001/jama.
2013.284427.
 < 140 / 90 mm Hg

For non-black population, initiate ACE inhibitor or ARB.

For black population, initiate thiazide-type diuretic, calcium channel blocker, ACE inhibitor, or ARB.

 

 

 

 

 

 

 

 

 

 

1 = first-line therapy; 2 = second-line therapy; 3 = third-line therapy

As the saying goes – out with the old and in with the new… Let us know which guidelines you and your practitioners are following for practice.  What blood pressure goal do you want to achieve with your patients?  What are your thoughts of these guidelines?

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