On behalf of the American Diabetes Association, a team of nine leading diabetes experts has reviewed and updated guidelines on the assessment and treatment of hypertension in people with diabetes. The detailed recommendations, which include a newly added pictorial algorithm for the treatment of confirmed hypertension in people with diabetes, are featured in the article, “Diabetes and Hypertension: A Position Statement by the American Diabetes Association,” published in the September 2017 issue of the journal Diabetes Care.

The prevalence of hypertension varies based upon a patient’s health, age, gender, family history of heart disease and genetics. Hypertension is a strong, yet modifiable risk factor for atherosclerotic cardiovascular disease (ASCVD), heart failure and microvascular complications. ASCVD refers to a buildup of fatty deposits in the arteries, which can result in issues such as myocardial infarction, stroke, peripheral arterial disease and more. ASCVD is the leading cause of morbidity and death among people with diabetes, as well as the largest contributor to the economic cost of diabetes. It is well established that treating hypertension impacts and reduces ASCVD events, heart failure and microvascular complications in people with diabetes.

The Association recommends that people with diabetes have blood pressure measurements taken at every routine clinical visit and, for people with diagnosed hypertension, taken at home as well. Blood pressure should also be measured while standing at the initial clinical evaluation to assess for orthostatic hypertension, a condition that may signal underlying nerve damage and influence blood pressure targets and treatment strategies. Patients with an elevated blood pressure (office-based measurements of 140/90 mmHg and above) should have their blood pressure con?rmed with multiple readings, including measurements on a separate day, to diagnose hypertension.

While the Association recommends a blood pressure target of less than 140/90 mmHg for most people with diabetes and hypertension, a lower blood pressure goal might be beneficial for some patients who have a high risk of cardiovascular disease. The position statement summarizes outcomes of clinical trials that have researched intensive hypertension treatment strategies, including the Action to Control Cardiovascular Risk in Diabetes blood pressure (ACCORD BP) trial; the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation–Blood Pressure (ADVANCEBP) trial; the Hypertension Optimal Treatment (HOT) trial; and the Systolic Blood Pressure Intervention Trial (SPRINT).

Lifestyle management plans for lowering blood pressure are also highlighted in the guidelines and include suggestions on weight loss, nutrition and increased physical activity. The statement also details, step-by-step, the recommended approach for the use of medication in the treatment of hypertension in people with diabetes, which depends on initial blood pressure, kidney health, response to treatment and adverse effects.

The Association provides detailed information regarding pregnancy, diabetes and hypertension. The statement emphasizes that women with preexisting hypertension or mild gestational hypertension (blood pressures less than 160/105 mmHg), and no evidence of end-organ damage, should not be treated with antihypertensive medications, as there is no benefit that clearly outweighs the potential risks. Blood pressure targets and potential medication guidelines are also included for pregnant patients with diabetes who do require treatment for hypertension.

Antihypertensive treatment for people with diabetes in the absence of hypertension is addressed, with the position statement indicating there is little evidence that blood pressure medication improves health outcomes in this group of patients.