Antihypertensive treatments for adults with type 2 diabetes

BMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i560 (Published 11 February 2016) Cite this as: BMJ 2016;352:i560
  1. Sumit R Majumdar, professor of medicine
  1. Department of Medicine, University of Alberta, Edmonton, Alberta, Canada T6G 2G3
  1. majumdar{at}ualberta.ca

Patients with diabetes need better blood pressure control, not more debate about the relative merits of different drugs

Clinically, pathophysiologically, and epidemiologically type 2 diabetes (hereafter, “diabetes”) and hypertension are tightly linked.1 About 50-60% of adults with diabetes have hypertension but only half with both conditions have adequate blood pressure control. Those with diabetes and hypertension are particularly susceptible to vascular injury because diabetes is associated with higher nocturnal pressures with greater 24 hour blood pressure load,2 impaired flow mediated autoregulation with associated microvascular injury, and stiffening of large arteries leading to increases in pulse pressure.1 Thus people with diabetes and hypertension are at an exponentially increased risk of death, myocardial infarction, heart failure, stroke, and end stage renal disease.2

How best to lower blood pressure in this population is an ongoing (and perhaps distracting) controversy that relates to whether or not diabetes is a “compelling indication” for using renin angiotensin system (RAS) blockers.3 The indications for RAS blockers are compelling—heart failure, established coronary disease, chronic kidney disease with proteinuria. But should diabetes be on this list? Experts and …

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