RSSDI Guidelines for the management of hypertension in patients with diabetes mellitus

Abstract

Hypertension and diabetes mellitus (DM) are two of the leading lifestyle diseases in the Indian and South Asian populations that often co-exist due to overlapping pathophysiological factors. Obesity, insulin resistance, inflammation, and oxidative stress are thought to be some common pathways. Up to 50% of hypertensive cases in India are diagnosed with type 2 diabetes mellitus (T2DM), which defines the need for a comprehensive guideline for managing hypertension in diabetic patients. These RSSDI guidelines have been formulated based on consultation with expert endocrinologists in India and Southeast Asia, acknowledging the needs of the Indian population. Ambulatory blood pressure monitoring and office and home-based blood pressure (BP) monitoring are recommended for the early analysis of risks. Cardiovascular risks, end-organ damage, and renal disorders are the primary complications associated with diabetic hypertension that needs to be managed with the help of non-pharmacological and pharmacological interventions. The non-pharmacological interventions include the nutrition education of the patient to reduce the intake of salt, sodium, and trans fats and increase the consumption of nuts, fresh fruits, vegetables, and potassium-rich foods. It is also recommended to initiate 50 to 60 min of exercise three to four times a week since physical activity has shown to be more beneficial for hypertension control in Indian patients than dietary modulation. For the pharmacological management of hypertension in patients with T2DM, angiotensin II receptor blockers (ARBs) are recommended as the first line of therapy, demonstrating their superiority over other antihypertensive agents such as ACEi. However, most of the global hypertension guidelines recommend initiation with combination therapy to achieve better BP control in most patients and to reduce the risk of adverse events. For combination therapy, calcium channel blockers (CCBs) are recommended to be administered along with ARBs instead of beta-blockers or diuretics to avoid the risk of cardiovascular events and hyperglycaemia. Among the CCBs, novel molecules (e.g. cilnidipine) are recommended in combination with ARBs for better cardiovascular and reno-protection in diabetic hypertensive patients.

Keywords: Diabetes mellitus; Hypertension; Macrovascular complication; Treatment.

Fig. 1

Recommendations for office blood pressure measurement [12]

Fig. 2

Relationship between hypertension and diabetes

Fig. 3

Diabetes and hypertension predispose to cardiovascular disease [45]

Fig. 4

Pathophysiological relationship between hypertension and chronic kidney disease [49]

Fig. 5

Different stages of hypertensive heart disease

Fig. 6

Mechanism of action of cilnidipine in the lowering of blood pressure in hypertensive patients [117]

Fig. 7

2012 KDIGO guidelines on the management of hypertension in diabetic/non-diabetic CKD patients

Fig. 8

Therapeutic approach in resistant hypertension [162]

Fig. 9

Summary of guideline