Managing Blood Pressure in Patients With Diabetes

Managing hypertension is a critical aspect of diabetes disease management.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: Let’s come back to hyperglycemia in a minute because this is the most exciting part of medicine right now, at least in our world of diabetes and metabolism. What about blood pressure management? What agents do you choose for blood pressure?

Jennifer B. Green, MD: For the most part, many of my patients already have some evidence of nephropathy or they may have coronary disease. If they have hypertension and those conditions, then what’s generally recommended as first-line therapy would be an ACE [inhibitor] or an ARB [angiotensin-receptor blocker] if they’re not already on other medications. If they’re on other medication, then the ACE or ARB needs to be introduced at that point. But most people with hypertension will require more than 1 drug. What you do beyond that can be customized a bit to the individual. Diuretics, calcium channel blockers, and beta-blockers, if they have indications for the same, all could be considered. But in a sense, it’s quite similar to the way we talk about the management of hyperglycemia. Hypertension also generally requires multiple agents to achieve individually appropriate targets.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: Yes, I agree. Usually, most people with diabetes and obesity need 2 or 3 medications to control high blood pressure, and it would go with the ACE and ARBs. There’s this belief that if blood pressure is normal and there’s no kidney problem, you still give ACE and ARB to prevent kidney problems. I don’t think that that’s ever been proven. That’s not recommended anymore. What do you do with lipid management?

Jennifer B. Green, MD: Lipid management is very simple. If you have diabetes and you’re 40 years of age or older, it’s a statin for everyone, essentially. Of course, if you have established ASCVD, or atherosclerotic cardiovascular disease, that has an indication for a high-intensity statin. It’s from that perspective that is the fundamental approach. Some people will need a different approach either because they can’t tolerate an adequate dose of statin therapy or the maximum tolerated dose isn’t adequate to control their LDL [low-density lipoprotein] cholesterol, or they may have particular issues. For example, triglyceride levels need a separate approach, but it’s very much a statin-based approach in this day and age.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: Is this what you’re doing? Or used to do?

Eugene E. Wright Jr, MD: That’s what I do. I recommend and like getting statins early. I try to explain to patients that we’re not just treating cholesterol. That’s 1 of the markers, but statin has reduced the risk in many other ways. Another way to follow it is what we see with their cholesterol. I try to get them to understand that we’re treating more than what they see.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: It’s like that pleiotropic impact of statins that you’re mentioning. [Jennifer] you said that the high-intensity statin is given at age 40. In the world today—Jaime, you may show us—so many people have heart disease. By the middle or early 30s, there are [a lot of] high rates of obesity…. I don’t like the cutoff age of 40 [years old]. I don’t think it makes sense. It has to do with the patient itself. I wish they would take away this high intensity, middle intensity, and lower intensity. It confuses the world. There should be just 2. By the way, a couple of places in Europe are already doing that. Just give it, and go down only if the patient can’t tolerate it. But that will reduce inertia and will change everything as you go to a max dose early on. You bring the LDL [low-density lipoprotein] down as much as you can. You bring the inflammation down as much as you can. If that patient needs special care, then you change what you do.

Jaime Murillo, MD: Let me connect that thought with something that you said before about the coronary artery calcium score. There was a model done to try to figure out the right time to start screening patients with diabetes. These were patients with type 1 diabetes screened by their calcium score. They found type 1 patients were around age 36 when they needed to start looking at that. When you look at the pathophysiology or think about it, if someone already has calcium at age 36, then that means they started to develop plaque at least 6 to 8 years earlier. That makes you think that there are certain groups where the risk is much higher.

Then we need to start thinking not so much in a binary way but in a patterned way. That’s where we have an opportunity. When I was listening to your discussion about what you do for diabetes, hypertension, and cholesterol, and all of a sudden you start thinking about this poor primary care doctor in the middle of a rural area who’s busy with a line of people, thinking “What should I do? What should I choose?” That’s where technology comes into play. It’s going to help us tremendously.

At a proof of concept in Detroit [Michigan], we screened for blood pressure in a 99% Black and medically underserved community. No. 1, the rates of hypertension were much higher than what we see in the literature. No. 2, we used an AI [artificial intelligence] power algorithm to treat blood pressure, and we found that if we follow the traditional guideline base sequence, it will take us longer to get there. The algorithm learned that there were a couple of medications that were 6 or 7 in line, but if we moved them up front, we could control blood pressure in 22 days. We’re almost done with that, and 91% of those patients had blood pressure control in less than 12 weeks because we were using that technology. That makes me think that when you think about the cardiorenal metabolic patient, we can certainly help the busy practitioner with some technology in an algorithm.

Eugene E. Wright Jr, MD: We see the same thing with glycemia. There are certain therapies that we’ve traditionally been late to use. If we use them earlier, we can get glycemic control much sooner.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: I love that what you showed us is the research. It shows that treat to failure is not a good model. We need to look at treat to success, not treat to failure. All studies of therapies with no fail, including a new study called GREAT that so many people are waiting to see how great it will be, are already designed to fail. The patient is designed to fail. There are always rescue medications. But when do you fail? Only if you fail do you go on another medication. By the way, that may be why diabetes is considered a progressive disease: we’ve never gotten diabetes to the lower level, where maybe their islet cells can regenerate [because] an islet cell can regenerate.

Transcript edited for clarity.

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