American Diabetes Association updates position statement on assessment and treatment of hypertension

The American Diabetes Association has released a new position statement updating its guidelines on the assessment and treatment of hypertension in individuals with diabetes. The update will be published in Diabetes Careonline and in the September print issue.  

A team of nine experts in endocrinology, nephrology, cardiology, and internal medicine from the United States, Europe, and Australia compiled the update, which they based on an intense review of research. In all, 137 of the most critical hypertension studies from around the world are referenced.

In these updated guidelines, the ADA recommends that people with diabetes have blood pressure (BP) measurements taken during every routine clinical visit. For those with diagnosed hypertension, measurements at home are recommended. In addition, to assess for orthostatic hypertension, BP should be measured while the patient is standing during the initial clinical exam. Those with elevated BP (office-based measurements of ≥ 140/90 mmHg) should have BP confirmed with multiple readings, including those taken on a separate day, to diagnose hypertension.

For most people with diabetes and hypertension, the ADA recommends a target BP of < 140/90 mmHg, but a lower goal may benefit those patients who may be at high risk of cardiovascular disease.

Included in the position statement are the outcomes of clinical trials that have assessed intensive hypertension treatment strategies, including the following:

• 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).

The guidelines also highlight lifestyle management as a way to lower BP, and include suggestions on weight loss, nutrition, and increased physical activity. It also offers a step-by-step outline of the recommended approach for the use of medications, which depends on initial BP, kidney health, response to treatment, and adverse effects.

Also included are recommendations on pregnancy, diabetes, and hypertension. In women with preexisting hypertension or mild gestational hypertension—defined as BP less than 160/105 mmHg—and no evidence of end-organ damage, antihypertensive medications should not be used as no benefit outweighs potential risks. BP targets and potential medication guidelines for pregnant patients with diabetes who do require anti-hypertensive treatment are also included.

Finally, one of the highlights of the updated guidelines is a new pictorial treatment algorithm.

“In the past two decades, we have seen a decrease in atherosclerotic cardiovascular disease (ASCVD) morbidity and mortality in people with diabetes, and evidence indicates that advances in BP control are likely the key to such improvements,” said the Association’s Chief Scientific, Medical & Mission Officer William T. Cefalu, MD. “As medical and pharmacological developments occur, it is imperative that medical providers, diabetes educators, and patients stay abreast of the most current care recommendations that can lead to improved cardiovascular health for people with diabetes and will ultimately result in better overall health and fewer diabetes-related complications.”