Вы находитесь на странице: 1из 8

European Review for Medical and Pharmacological Sciences 2011; 15: 1256-1263

Hypertension management in diabetic patients


Z. ANWER, P.K. SHARMA, V.K. GARG, N. KUMAR, A. KUMARI

Department of Pharmaceutical Technology, Meerut Institute of Engineering and Technology, NH-58,


Baghpat By-pass Crossing, Delhi-Haridwar Highway, Meerut (India)

Abstract. – Hypertension and diabetes are Stage two hypertension: consistent readings of
becoming increasingly common. Clinical trials 160/100 mmHg or higher.
have demonstrated the importance of tight Pre-hypertension: consistent readings of 120-
blood pressure control among patients with dia-
betes. However, little is known regarding the 139/80-89 mmHg.
management of hypertension in patients with
coexisting diabetes. Most patients with both dis- Diabetes mellitus often simply referred to as
orders have a markedly worsened risk for pre- diabetes is a condition in which a person has a
mature micro vascular and macro vascular com- high blood sugar level, either because the body
plications. The appropriate management of the doesn’t produce enough insulin, or because body
hypertension seen in almost 70% of patients
with type 2 diabetes mellitus remains controver-
cells don’t properly respond to the insulin that is
sial. However, over the past few years, many ran- produced3. There are many types of diabetes, the
domized, controlled trials have provided guid- most common of which are4:
ance for more effective therapy. These trials
have established the need for a lower goal blood Type 1 diabetes: results from the body’s failure
pressure (<130/80 mm Hg) than has previously to produce insulin, and presently requires the
been recommended. To achieve therapy goals, person to inject insulin.
multiple antihypertensive drugs are usually
needed. Type 2 diabetes: results from insulin resistance,
a condition in which cells fail to use insulin
Key Words: properly, sometimes combined with an ab-
solute insulin deficiency.
Hypertension, Diabetes mellitus, Macrovascular, Mi- Gestational diabetes: it is when pregnant women,
crovascular, Cardiovascular disease.
who have never had diabetes before and have
high blood glucose level during pregnancy. It
may precede development of type 2 diabetes
mellitus.

Introduction Other forms of diabetes mellitus include con-


genital diabetes, which is due to genetic defects
Hypertension (defined as a blood pressure of insulin secretion, cystic fibrosis-related dia-
≥140/90 mmHg) is an extremely common condi- betes, steroid diabetes induced by high doses of
tion in diabetes, affecting ∼20-60% of patients gluco-corticoids, and several forms of monogenic
with diabetes, depending on obesity, ethnicity, diabetes.
and age. Hypertension is a condition in which
blood pressure is high. It can be caused by genet-
ics, diet as well as stress. It is associated with How are Diabetes and
significant health problems such as stroke and Hypertension Related?
heart attack1,2. The following clinical levels of
hypertension1,2 have been described by The Na- Diabetes and high blood pressure tend to occur
tional Heart, Lung, and Blood Institute: together because they share certain physiological
traits. High blood pressure is a dangerous disease
Stage one hypertension: consistent (i.e., two or that becomes even more problematic in the setting
more consecutive) readings of 140-159/90-99 of diabetes. Unfortunately, many people with dia-
mmHg. betes are also affected by high blood pressure, and

1256 Corresponding Author: Zaihra Anwer, MD; nghtyme@gmail.com


Hypertension management in diabetic patients

the two diseases commonly occur together5-7. Dia- The well-studied example of the self-reinforcing
betes and high blood pressure occur together so relationship between diabetes and high blood pres-
frequently that they are officially considered to be sure takes place in the kidneys. The kidneys are the
“comorbidities” (diseases likely to be present in the body’s most important long-term blood pressure
same patient). In the case of diabetes and high regulator. By balancing the amount of salt and
blood pressure, these effects include: potassium in the body, the kidneys ultimately con-
trol how much fluid is excreted as urine. This fluid
Increased Fluid Volume – Diabetes increases regulating function helps to modulate long-term
the total amount of fluid in the body, which blood pressure by physically controlling how much
tends to raise blood pressure. liquid is present in the blood vessels.
Increased Arterial Stiffness – Diabetes can de-
crease the ability of the blood vessels to
stretch, increasing average blood pressure. Relationship Between Diabetes
Impaired Insulin Handling – Changes in the and Hypertension
way the body produces and handles insulin
can directly cause increases in blood pressure. Figure 1 shows the interrelationship between
the hyperglycemia and the hypertension through
Apart from above factors the two diseases are the intervention of insulin resistance, a common
likely to occur together simply because they link between the two diseases.
share a common set of risk factors. Some impor-
tant shared risk factors are: Statistical Relationship
Individuals with diabetes are at a much greater
Body Mass – Being overweight significantly in- risk for developing. Hypertension is twice as
creases the risk of both diabetes and high common in those with diabetes as in non diabetic
blood pressure. individuals1,2,8.
Diet – High fat diets rich in salt and processed
sugars are known to contribute to the develop- Physical Relationship
ment of organ problems that can lead to both Diabetes causes hyperinsulinemia and raises
diabetes and high blood pressure. the risk of hypertension. This condition increases
Activity Level – A low level of physical activity the amount of sodium that the body absorbs. It
makes insulin less effective (which can lead to also promotes the stimulation of the sympathetic
diabetes) and can contribute to the develop- nervous system. This is thought to cause changes
ment of stiff blood vessels, increasing the risk in blood vessel structure, which affects the func-
of high blood pressure. tion of the heart and blood pressure1,2,8.

Figure 1. Metabolic syndrome.

1257
Z. Anwer, P.K. Sharma, V.K. Garg, N. Kumar, A. Kumari

Obesity Guidelines for the Management


Metabolism is related to obesity, which is re- of Hypertension
lated to diabetes, which is related to hyperten-
sion. Reducing in weight can often lower blood Effective blood pressure control is an impor-
pressure. This lowering of hypertension symp- tant goal for diabetic patients. The patients who
toms is associated with a decrease in the symp- suffer from both diabetes and hypertension have
toms of diabetes1,2,8. greater chances of developing cardiovascular dis-
order10. The following guidelines must be consid-
ered for the management of hypertension in dia-
Evidences betic patients:

Hypertension as a Risk Factor for Measurement of Arterial Blood Pressure: The


Complications of Diabetes object of identifying and treating high blood
Diabetes increases the risk of coronary events pressure is to reduce the risk of cardiovascular
two fold in men and four fold in women. This in- disorder and associated morbidity and mortali-
crease is due to the frequency of associated car- ty. It is, therefore, necessary to provide a clas-
diovascular risk factors such as hypertension, sification of blood pressure in adults so as to
dyslipidemia and clotting abnormalities. People identify the high risk individuals and to pro-
with both diabetes and hypertension have ap- vide guidelines for treatment and follow up.
proximately twice the risk of cardiovascular dis- Arterial blood pressure measured in the sitting
ease as non-diabetic people with hypertension. position should be considered as ideal11.
Hypertensive diabetic patients are also at in- Systolic and Diastolic Pressure Target Values:
creased risk for diabetes-specific complications The level to which blood pressure should be
including retinopathy and nephropathy1,2. reduced in a diabetic hypertensive patient has
not been known12. There are no specific guide-
Evidence for Target Levels of lines on the exact values for hypertension con-
Blood Pressure in Patients with Diabetes trol in diabetes. A number of epidemiological
The UK Prospective Diabetes Studies studies suggest an inverse relationship exist
(UKPDS) and the Hypertension Optimal Treat- between calcium, magnesium, potassium in-
ment (HOT) trial both demonstrated improved take and blood pressure level 13-15. Most of
outcomes, especially in preventing stroke, in pa- these studies are cross-sectional, but none of
tients assigned to lower blood pressure targets. these studies has analyzed diabetic patients
Optimal outcomes in the HOT study were separately from the general hypertension pop-
achieved in the group with a target diastolic ulation. There are no randomized clinical trials
blood pressure of 80 mmHg. Randomized clini- on magnesium supplementation in diabetic
cal trials demonstrate the benefit of targeting a subjects with hypertension.
diastolic blood pressure of ≤80 mmHg. Epi- Screening and Initial Evaluation: All patients
demiological analyses show that blood pres- with diabetes should have blood pressure mea-
sures ≥120/70 mmHg are associated with in- sured at the time of diagnosis and at each
creased cardiovascular event rates and mortality scheduled diabetes visit13. Initial assessment of
in persons with diabetes. Therefore, a target a hypertensive diabetic patient should include
blood pressure goal of <130/80 mmHg is rea- a complete medical history with special em-
sonable if it can be safely achieved. Achieving phasis on cardiovascular risk factors and the
lower levels, however, would increase the cost presence of diabetes complication. The physi-
of care as well as drug side effects and is often cal exam should include height, weight, and
difficult in practice1,2. careful evaluation of arterial circulation. Initial
laboratory examination should include serum
creatinine, electrolytes, fasting lipid profile,
Types of Hypertension in Diabetes Mellitus and urinary albumin excretion16.
Behavioral Treatments of Hypertension: Di-
1. Essential hypertension etary management with moderate sodium re-
2. Hypertension consequent to nephropathy striction has been effective in reducing blood
3. Isolated systolic hypertension pressure in individuals with essential hyper-
4. Supine hypertension with orthostatic fall9 tension17,18. Weight reduction can reduce blood

1258
Hypertension management in diabetic patients

pressure independent of sodium intake and can hydrochlorothiazide) are generally well toler-
also improve blood glucose and lipid levels19. ated and not associated with adverse metabolic
Sodium restriction has not been tested in the effects31. Thiazide diuretics are not as effective
diabetic population in controlled clinical trials. in patients with renal insufficiency; in such pa-
Reductions in daily sodium intake to levels of tients, loop diuretics are preferred.
10-20 mmol (230-460 mg) per day have re- Calcium Channel Blockers (CCB): Controver-
sulted in decreases in systolic blood pressure sy exists regarding the use of CCBs, particu-
of 10-12 mmHg 17. Smoking cessation and larly the dihydropyridines (e.g., amlodipine,
moderation of alcohol intake are also recom- nifedipine) in treating hypertension in patients
mended to reduce blood pressure20-22. with diabetes. The combination of an ACE in-
hibitor and a dihydropyridine CCB has been
shown to reduce proteinuria2. The nondihy-
Treatment Goals dropyridine CCBs (e.g., verapamil) demon-
strate reductions in cardiovascular risk when
In the setting of diabetes, the target blood used as monotherapy. Combining a nondihy-
pressure is <130/80. Significant improvements in dropyridine CCB with an ACE inhibitor in hy-
long term cardiovascular and kidney health do pertensive patients with diabetes is associated
not become apparent until blood pressure is re- with greater reductions in proteinuria than if
duced to this level. Because it is difficult to re- either agent was used individually2,32.
duce blood pressure to this level, it is a recom- Angiotensin II Receptor Blockers (ARB):
mendation usually reserved only for specific pa- Candesartan and lisinopril are used to treat
tients23-25. patients with type 2 diabetes, hypertension,
and microalbuminuria33. Candesartan is as ef-
Drug Therapy fective as lisinopril in blood pressure reduction
Drug therapy is a necessary step for most pa- and minimization of microalbuminuria 34-35.
tients during treatment. Vast amounts of re- Losartan therapy produced a renoprotective ef-
search have been done in an effort to determine fect independent of its blood-pressure-lower-
which drug or drug combination is the “best” ing effect in patients with type 2 diabetes and
for treating high blood pressure in patients with nephropathy 35,36. Irbesartan is found to be
diabetes. The best drugs to use in the setting of renoprotective in patients with type 2 diabetes
diabetes are: who have microalbuminuria. Valsartan lowers
urine albumin excretion to a greater degree
Angiotensin Converting Enzyme (ACE) In- than amlodipine in type 2 diabetic patients
hibitors: ACE inhibitors have proved benefi- with microalbuminuria37.
cial in patients who have myocardial infarc- Beta Blockers: Traditionally, the use of beta
tion or congestive heart failure, or who have blockers in patients with diabetes has been dis-
diabetic renal disease10. ACE inhibitor thera- couraged because of adverse metabolic effects
py results in 20 to 30 percent decrease in the and the masking of hypoglycemic symptoms.
risk of stroke, coronary heart disease, and There is no difference in hypoglycemic
major cardiovascular events 26,27 . ACE in- episodes in patients treated with atenolol com-
hibitors are found to be more beneficial when pared with captopril, but the mean weight gain
compared with other antihypertensives in the in the atenolol group was greater28. Cardio se-
reduction of acute myocardial infarction, car- lective beta blockers are preferred over the
diovascular events, and mortality. Captopril non-selective type because they are associated
and atenolol are similar in terms of reduction with less blunting of hypoglycemic awareness
in microvascular and macrovascular compli- and less elevation of lipid and glucose levels.
cations28. The alpha beta blocker carvedilol causes fewer
Diuretics: Thiazide diuretics have been shown to alterations in lipid and glucose levels com-
benefit patients with diabetes and systolic hy- pared with traditional beta blockers38. Beta-
pertension. Chlorthalidone therapy is effective blocker therapy can be advantageous in many
in preventing major cerebrovascular and car- patients with diabetes because of its proven
diovascular events in older non-insulin-treated ability to decrease cardiovascular morbidity
patients with diabetes and isolated systolic hy- and mortality in persons with atherosclerotic
pertension. Lower dosages of thiazides (e.g., heart disease39.

1259
Z. Anwer, P.K. Sharma, V.K. Garg, N. Kumar, A. Kumari

Renin Inhibitors: A new and promising ap- • Patients with a systolic blood pressure of 130-
proach in rennin angiotensin aldosterone sys- 139 mmHg or a diastolic blood pressure of 80-
tem blockade has been started with the de- 89 mmHg must be given lifestyle/behavioral
velopment of first direct renin inhibitor, therapy for a period of 3 months and then
aliskiren, recently approved by US Food and should be treated pharmacologically with
Drug Administration (FDA) for the treatment agents that block the renin-angiotensin system.
of hypertension in diabetic patients. • In addition to lifestyle/behavioral therapy pa-
Aliskiren is generally well tolerated and, in tients with hypertension should receive drug
contrast to ACE inhibitors, it does not induce therapy.
accumulation of substance P or bradykinin. • Multiple drug therapy is generally required to
Therefore, side effects such as cough and an- achieve blood pressure targets.
gioedema are very rare. It has demonstrated • For those having blood pressure ≥ 140/90
a favorable safety and tolerability profile should be given drug to reduce cardio-vascular
alone or in combination with other drugs39. disorder events.
Aliskiren monotherapy demonstrated signifi- • All patients with diabetes and hypertension
cant, dose-dependent antihypertensive effects should be treated with a regimen that includes
in several placebo-controlled clinical trials40. an ACE inhibitor or ARB. If one is not tolerat-
Renin inhibition seems an interesting new ed, the other should be given. If blood pressure
approach for preventing the progression of targets are to be achieved, a thiazide diuretic
chronic kidney disease41. should be added.
• If ACE inhibitors or ARBs are used, renal
Combination Therapy function and serum potassium levels should be
Diabetes and hypertension constitute a par- monitored.
ticularly dangerous combination with respect to • In patients with type 1 diabetes with hyperten-
cardiovascular morbidity and mortality. A sig- sion and any degree of albuminuria, ACE in-
nificant increase in systolic blood pressure in hibitors have been shown to delay the progres-
any age group leads to significant increase in sion of nephropathy.
cardiovascular disease. Therefore, it is neces- • In patients with type 2 diabetes, hypertension,
sary to reduce blood pressure42. Most patients and microalbuminuria, ACE inhibitors and
with hypertension and diabetes require more ARBs have been shown to delay the progres-
than one agent to attain adequate blood pres- sion to macroalbuminuria.
sure control. In the HOT (Hypertension Opti- • In those with type 2 diabetes, hypertension,
mal Treatment) trial, 68% of patients were macroalbuminuria and renal insufficiency, an
maintained on combination antihypertensive angiotensin receptor blocker should be strong-
therapy. The combination of ACE inhibitors ly recommended.
and CCBs is associated with a reduction in car- • In elderly hypertensive patients, blood pres-
diovascular events and protein-urea 2,43-46. The sure should be lowered gradually to avoid
combination of a dihydropyridine and a nondi- complications.
hydropyridine CCB has been shown to have a • Patients not achieving target blood pressure on
synergistic blood-pressure-lowering potential47. three drugs, including a diuretic and patients
Caution should be used with the combination with a significant renal disease should be re-
of nondihydropyridine CCBs and beta blockers ferred to a physician experienced in the care of
because of the potential for additive negative patients with hypertension1,2.
cardiac inotropic effects. Combinations of beta
blockers and ACE inhibitors have shown few Non-Drug Therapy
additive effects on blood pressure when used in This therapy mainly includes weight loss, salt
patients with a pulse rate of less than 84 beats restriction, dietary changes, quitting smoking,
per minute 48 . The final phase of the CALM limiting alcohol intake, etc29-31. In patients with-
(candesartan and lisinopril microalbuminuria) out diabetes, strict adherence to these rules very
study examined combination treatment with often leads to significant drops in blood pressure
candesartan and lisinopril33. so much that drug therapy may not be needed. In
The following steps are required for combina- the Dietary Approaches to Stop Hypertension tri-
tion treatment of hypertension in diabetic pa- al, lifestyle modifications such as exercise and a
tients: diet low in salt and high in potassium have clear-

1260
Hypertension management in diabetic patients

ly been shown to decrease blood pressure49. Ex- 6) HYPERTENSION IN DIABETES STUDY (HDS): I. Prevalence
cessive sodium intake is particularly deleterious of hypertension in newly presenting type 2 diabet-
ic patients and the association with risk factors for
in patients with diabetes because it may decrease cardiovascular and diabetic complications. J Hy-
the antihypertensive effects of medications and pertens 1993; 11: 309-317.
their beneficial effects on protein urea50. Weight
7) SOWERS JR, EPSTEIN M, FROHLICH ED. Diabetes, hy-
loss and exercise can help to lower blood pres- pertension, and cardiovascular disease: an up-
sure and may also improve glycaemic control date. Hypertension 2001; 37: 1053.
and insulin sensitivity.
8) CONY DB, TUCK ML. Advances in hypertension. Am
J Nephrol 1996; 16: 223-236.
9) DAS S. Etiopathogenesis of hypertension in dia-
betes mellitus. Int J Diab Dev Count 1995; 15:
Conclusion 106-109.

Control of hypertension and maintenance of 10) THE SIXTH REPORT OF THE JOINT NATIONAL COMMITTEE
ON P REVENTION , Detection, Education and treat-
ideal blood pressure is the moot point that would
ment of High Blood Pressure. Arch Int Med 1997;
benefit the diabetic patient most. Pharmacists 157: 2413-2467.
must become more vigilant about current guide-
lines for the treatment of patients with concomi- 11) KUMAR A. Indian scenario–hypertension. In: Das S
Ed. Complications of Diabetes in Indian Secnario.
tant hypertension and type 2 diabetes mellitus. USV Ltd Mumbai; 2000.
Strategies such as patient education and medica-
tion assessment can help to optimize care for 12) RUILOPE LM, GARCI R. How far should blood pres-
sure be reduced in diabetic hypertensive pa-
these patients and slow the progression to diabet- tients? J Hypertens 1997; 15: 63-65.
ic nephropathy. Many patients with diabetes mel-
litus and hypertension are not been treated ac- 13) GELEIJNSE JM, WITTEMAN JC, BAK AA, BREEIJEN JH,
GROBBEE DE. Reduction in blood pressure with a
cording to guidelines. Specific risk factors deter- low sodium, high potassium, high magnesium salt
mined may aid in identifying patients at high-risk in older subjects with mild to moderate hyperten-
for inadequate treatment. Patient and education sion. Br Med J 1994; 309: 436-440.
provider, public health approaches, and health 14) MOORE TJ, MCKNIGHT JA. Dietary factors and blood
system changes are needed to address these is- pressure regulation. Endocrinol Metab Clin North
sues. As the population grows older and contin- Am 1995; 24: 543-555.
ues to gain weight, diabetes and hypertension 15) MORRIS CD, REUSSER ME. Calcium intake and blood
will become even more common. It is to be pressure: epidemiology revisited. Semin Nephrol
hoped that an approach similar to that outlined 1995; 15: 490-495.
here can limit their serious consequences. 16) MASER RE, PFEIFER MA, DORMAN JS, KULLER LH, BECK-
ER DJ, ORCHARD TJ. Diabetic autonomic neuropathy
and cardiovascular risk: the Pittsburgh Epidemiol-
ogy of Diabetes Complications Study III. Arch Int
References Med 1990; 150: 1218-1222.
17) CUTLER JA, FOHNANN D, ALLENDER PS. Randomized
1) ARAUZ-PACHECO C, PARROTT MA, RASKIN P. The treat- trials of sodium reduction: an overview. Am J Clin
ment of hypertension in adult patients with dia- Nutr 1997; 65: 643-651.
betes. Diabetes Care 2002; 25: 134-147.
18) MIDGLEY JP, MATTHEW AG, GREENWOOD CM, LOGAN
2) BAKRIS GL, WILLIAMS M, DWORKIN L, ELLIOTT WJ, EP- AG. Effect of reduced dietary sodium on blood
STEIN M, TOTO R, TUTTLE K, DOUGLAS J, HSUEH W,
pressure: a meta-analysis of randomized con-
SOWERS J. Preserving renal function in adults with trolled trials. JAMA 1996; 275: 1590-1597.
hypertension and diabetes: a consensus ap-
proach. Am J Kidey Dis 2000; 36: 646-661. 19) S TAESSEN J, FAGARD R, L IJNEN P, A MERY A. Body
weight, sodium intake and blood pressure. J Hy-
3. ROTHER KI. Diabetes treatment-bridging the divide.
pertens 1989; 7: 19-23.
N Engl J Med 2007; 15: 1499-1501.
4) T IERNEY LM, M C P HEE SJ, PAPADAKIS MA. Current 20) C HOBANIAN AV, B AKRIS GL, B LACK HR, C USHMAN
medical Diagnosis & Treatment. 40th ed. New WC, GREEN LA, IZZO JL, JONES DW, MATERSON BJ,
Yo r k : L a n g e M e d i c a l B o o k s / M c G raw - H i l l ; OPARIL S, WRIGHT JT, ROCCELLA EJ. Joint National
2001. Committee on Prevention, Detection, Evalua-
tion and Treatment of High Blood Pressure:
5) EPSTEIN M, SOWERS JR. Diabetes mellitus and hyper- The Sixth Report of the Joint National Commit-
tension. Hypertension 1992; 19: 403. tee on Prevention, Detection, Evaluation and

1261
Z. Anwer, P.K. Sharma, V.K. Garg, N. Kumar, A. Kumari

Treatment of High Blood Pressure (JNC VI). 31) FINEBERG SE. The treatment of hypertension and
Arch Int Med 1997; 157: 2413-2446. dyslipidemia in diabetes mellitus. Prim Care
21) HAIRE-JOSHU D, GLASGOW RE, TIBBS TL. Smoking and 1999; 26: 951-964.
diabetes (Position Statement). Diabetes Care 32) BAKRIS GL, WEIR MR, DEQUATTRO V, MCMAHON FG.
2002; 25: 80-81. Effects of an ACE inhibitor/calcium antagonist
22) HAIRE-JOSHU D, GLASGOW RE, TIBBS TL. Smoking and combination on proteinuria in diabetic nephropa-
diabetes (Technical Review). Diabetes Care thy. Kidney Int 1998; 54: 1283-1289.
1999; 22: 1887-1889. 33) M OGENSEN CE, N ELDAM S, T IKKANEN I, O REN S,
23) ALLHAT OFFICERS AND COORDINATORS FOR THE ALL- VISKOPER R, WATTS RW, COOPER ME. Randomized
HAT COLLABORATIVE RESEARCH GROUP. The Antihy- controlled trial of dual blockade of renin an-
pertensive and Lipid-Lowering Treatment to giotensin system in patients with hypertension,
Prevent Heart Attack Trial. Major outcomes in microalbuminuria, and non-insulin dependent
high-risk hypertensive patients randomized to diabetes: the candesartan and lisinopril microal-
angiotensin-converting enzyme inhibitor or cal- buminuria (CALM) study. Br Med J 2000; 321:
cium channel blocker versus diuretic: The Anti- 1440-1444.
hypertensive and Lipid-Lowering Treatment to 34) BRENNER BM, COOPER ME, DE ZD, KEANE WF, MITCH
Prevent Hear t Attack Trial (ALLHAT). JAMA WE, PARVING HH, REMUZZI G, SNAPINN SM, ZHANG Z,
2002; 288: 2981-2997. SHAHINFAR S. Effects of losartan on renal and car-
24) BUSE JB, GINSBERG HN, BAKRIS GL, CLARK NG, COSTA diovascular outcomes in patients with type 2 dia-
F, E CKEL R, F ONSECA V, G ERSTEIN HC, G RUNDY S, betes and nephropathy. N Engl J Med 2001; 345:
NESTO RW, PIGNONE MP, PLUTZKY J, PORTE D, REDBERG 861-869.
R, STITZEL KF, STONE NJ; AMERICAN HEART ASSOCIATION; 35) PARVING HH, LEHNERT H, BRÖCHNER-MORTENSEN J,
AMERICAN DIABETES ASSOCIATION. Primary prevention GOMIS R, ANDERSEN S, ARNER P; IRBESARTAN IN PA-
of cardiovascular diseases in people with dia- TIENTS WITH T YPE 2 D IABETES AND M ICROALBUMINURIA
betes mellitus: a scientific statement from the STUDY GROUP. The effect of irbesartan on the de-
American Heart Association and the American velopment of diabetic nephropathy in patients
Diabetes Association. Circulation 2007; 115: 114- with type 2 diabetes. N Engl J Med 2001; 345:
126. 870-878.
25) GAEDE P, VEDEL P, PARVING HH, PEDERSEN O. Intensi- 36) PARVING HH, PERSSON F, LEWIS JB, LEWIS EJ, HOLLEN-
fied multifactorial intervention in patients with type BERG NK; AVOID S TUDY I NVESTIGATORS . Aliskiren
2 diabetes mellitus and microalbuminuria: The combined with losartan in type 2 diabetes and
Steno type 2 randomized study. Lancet 1999; nephropathy. N Engl J Med 2008; 358: 2433-
353: 617-622. 2446.
26) NEAL B, MACMAHON S, CHAPMAN N. Blood Pressure 37) VIBERTI G, WHEELDON NM. Microalbuminuria reduc-
Lowering Treatment Trialists' Collaboration. Ef- tion with valsartan in patients with type 2 diabetes
fects of ACE inhibitors, calcium antagonists, and mellitus: a blood pressure-independent effect. Cir-
other blood-pressure-lowering drugs: results of culation 2002; 106: 672-678.
prospectively designed overviews of randomized
38) G IUGLIANO D, A CAMPORA R, M ARFELLA R, D E RN,
trials. Lancet 2000; 356: 1955-1964.
ZICCARDI P, RAGONE R, DEANGELIS L, D’ONOFRIO F.
27) PAHOR M, PSATY BM, ALDERMAN MH, APPLEGATE WB, M e t a b o l i c a n d c a r d i ova s c u l a r e f fe c t s o f
WILLIAMSON JD, FURBERG CD. Therapeutic benefits carvedilol and atenolol in non-insulin-depen-
of ACE inhibitors and other antihypertensive dent diabetes mellitus and hypertension. A ran-
drugs in patients with type 2 diabetes. Diabetes domized controlled trial. Ann Intern Med 1997;
Care 2000; 23: 888-892. 126: 955-959.
28) UK PROSPECTIVE DIABETES STUDY GROUP. Efficacy of 39) RASHID H. Direct renin inhibition: an evaluation of
atenolol and captopril in reducing risk of the safety and tolerability of aliskiren. Curr Med
macrovascular and microvascular complications Res Opin 2008; 24: 2627-2637.
in type 2 diabetes: UKPDS 39. Br Med J 1998;
317: 713-720. 40) TEKTURNA (ALISKIREN). Prescribing information. Avail-
able at:http://www.fda.gov.
29) VAUGHAN DE, ROULEAU JL, RIDKER PM, ARNOLD JM,
MENAPACE FJ, PFEFFER MA. Effects of ramipril on 41) LIVIU S, KEREM A, DAVID G. Direct renin inhibitors-
plasma fibrinolytic balance in patients with nuance or necessity? Eur Ren Dis 2007; 2: 41-
acute anterior myocardial infarction. HEART 43.
Study Investigators. Circulation 1997; 96: 442- 42) LEWINGTON S, CLARKE R, QIZILBASH N, PETO R, COLLINS
447. R. Age-specific relevance of usual blood pressure
30) DI PASQUALE P, VALDES L, ALBANO V, BUCCA V, SCALZO to vascular mortality: a meta-analysis of individual
S, PIERI D, MARINGHINI G, PATERNA S. Early captopril data from one million adults in 61 prospective
treatment reduces plasma endothelin concentra- studies. Lancet 2002; 360: 1903-1913.
tions in the acute and sub acute phases of my- 43) TATTI P, PAHOR M, BYINGTON RP, DI MP, GUARISCO R,
ocardial infarction: a pilot study. J Cardiovasc STROLLO G, STROLLO F. Outcome results of the Fos-
Pharmacol 1997; 29: 202-208. inopril Versus Amlodipine Cardiovascular Events

1262
Hypertension management in diabetic patients

Randomized Trial (FACET) in patients with hyper- 47) SASEEN JJ, CARTER BL, BROWN TE, ELLIOTT WJ, BLACK
tension and NIDDM. Diabetes Care 1998; 21: HR. Comparison of nifedipine alone and with dilti-
597-603. azem or verapamil in hypertension. Hypertension
44) HANSSON L, ZANCHETTI A, CARRUTHERS SG, DAHLOF B, 1996; 28: 109-114.
ELMFELDT D, JULIUS S, MENARD J, RAHN KH, WEDEL H, 48) BELZ GG, BREITHAUPT K, ERB K, KLEINBLOESEM CH,
WESTERLING S. Effects of intensive blood-pressure WOLF GK. Influence of the angiotensin converting
lowering and low-dose aspirin in patients with hy- enzyme inhibitor cilazapril, the beta-blocker pro-
pertension: principal results of the Hypertension pranolol and their combination on haemodynam-
Optimal Treatment (HOT) randomized trial. ics in hypertension. J Hypertens 1989; 7: 817-
Lancet 1998; 351: 1755-1762. 824.
45) TUOMILEHTO J, RASTENYTE D, BIRKENHAGER WH, THIJS L, 49) MOORE TJ, CONLIN PR, ARD J, SVETKEY LP. DASH
ANTIKAINEN R, BULPITT CJ, FLETCHER AE, FORETTE F, GOLD- (Dietary Approaches to Stop Hypertension) diet
HABER A, PALATINI P. Effects of calcium-channel block- is effective treatment for stage 1 isolated sys-
ade in older patients with diabetes and systolic hy- tolic hypertension. Hypertension 2001; 38: 155-
pertension. N Engl J Med 1999; 340: 677-684. 158.
46) WANG JG, STAESSEN JA, GONG LL, LIU L. For the Sys- 50) BAKRIS GL, SMITH A. Effect of sodium intake on
tolic Hypertension in China (Syst-China) Collabo- albumin excretion in patients with diabetic
rative Group. Chinese trial on isolated systolic hy- nephropathy treated with long-acting calcium
pertension in the elderly. Arch Intern Med 2000; antagonists. Ann Intern Med 1996; 125: 201-
160: 211-220. 204.

1263

Вам также может понравиться