IX. Treatment of hypertension in association with diabetes mellitus

Prevention and Treatment

Recommendations

  1. Persons with diabetes mellitus should be treated to attain SBP of < 130 mm Hg (Grade C) and DBP of < 80 mm Hg (Grade A; these target BP levels are the same as the BP treatment thresholds).
  2. For persons with cardiovascular or kidney disease, including microalbuminuria, or with cardiovascular risk factors in addition to diabetes and hypertension, an ACE inhibitor or an ARB is recommended as initial therapy (Grade A).
  3. For persons with diabetes and hypertension not included in other recommendations in this section, appropriate choices include (in alphabetical order): ACE inhibitors (Grade A), ARBs (Grade B), dihydropyridine CCBs (Grade A), and thiazide/thiazide-like diuretics (Grade A).
  4. If target BP levels are not achieved with standard-dose monotherapy, additional antihypertensive therapy should be used. For persons in whom combination therapy with an ACE inhibitor is being considered, a dihydropyridine CCB is preferable to a thiazide/thiazide-like diuretic (Grade A).

Hypertension in Chronic Kidney Disease

New recommendations for 2020

  • Individualize BP targets in patients with chronic kidney disease. Consider intensive targets (SBP < 120 mm Hg) in appropriate patients.

In nondiabetic chronic kidney disease patients who meet the inclusion criteria for the Systolic Blood Pressure Intervention Trial (SPRINT; age older than 50 years, at elevated cardiovas-cular risk with SBP 130-180 mm Hg; Table 6),71 we endorse a target SBP < 120 mm Hg. There was no evidence of hetero-geneity of effect across prespecified subgroups; therefore, the benefits observed in the intervention group as a whole should also be experienced by those with nondiabetic kidney disease. However, it should also be acknowledged that SPRINT only enrolled 2646 participants with a GFR < 60 mL/min/1.73 m2 of an intended 4600, so the evaluation of heterogeneity of ef-fects might be underpowered. In patients with adult polycystic kidney disease, an SBP < 110mm Hg should be targeted on the basis of the HALT Progression of Polycystic Kidney Disease (HALT-PKD) trial,72 which showed a slower increase in total kidney volume, a greater decline in left ventricular mass index, and a greater reduction in urinary albumin excretion compared with standard BP control. The in-clusion and exclusion criteria for the SPRINT trial likely captured primarily patients with hypertension-related chronic kidney disease. Consequently, there is currently insufficient evidence to support a target SBP as per the SPRINT trial in nondiabetic chronic kidney disease patients who meet the exclusion criteria for the SPRINT trial (eg, patients with advanced chronic kidney disease [eGFR < 20 mL/min/1.73 m2], proteinuria > 1 g/d, adult polycystic kidney disease, glomerulonephritis, and those who are institutionalized and/or frail).

Further reduction in SBP target may be individualized at the discretion of the treating physician, considering the patient’s specific kidney disease, comorbidities, and age. Moreover, Hypertension Canada recommends that potential benefits and adverse events related to lower SBP targets be discussed with each patient and therapeutic decisions should be shared.