hypertension & diabetes: new guidelines janice douglas, md case western university cleveland, oh...

Hypertension & diabetes: new guidelines

Janice Douglas, MDCase Western UniversityCleveland, OH

George L Bakris, MDDirector of the Hypertension/Clinical Research Center at Rush Medical CollegeChicago, IL

What we know

Hypertension and diabetes

More than 11 million Americans have both diabetes and hypertension as comorbid diseases.

Increases in:urinary albumin excretionhyperuricemiadyslipidemiasleft ventricular hypertrophy

Diabetes is the leading cause of end-stage renal disease in the general population.

Basis of NKF guidelines


Based on JNC VI guidelines: BP <130/85

Trials suggest linear relationship between lower BP and lower cardiovascular risk(HOT, UKPDS)

NKF guidelines: <130/80

Bakris GL, et al. Am J Kidney Dis 2000;36(3):646-661

Achieving the goal


If BP >145/90, 2 or more medications needed to reach goal

ACE inhibitor/diuretic is ideal starting combination

Titrate ACE to max, keep diuretic low dose

Watch for pulse rates higher than 84

Medication


An average of 3.2 different antihypertensives are needed to reach this goal.

The worse the renal function, the more medications you need (4 or 5).

Importance of BP management


Tight BP control stronger than tight glucose control for lowering risk of:

strokedeath by diabetesany diabetic endpointmicrovascular complications

(UKPDS) BMJ 1998 Sep 12;317(7160):703-13


“I think it is critically important that the goal blood pressure be achieved [and that] people not become wimpy in terms of their anti-hypertensive medication doses.”

George L Bakris, MDDirector of the Hypertension/ClinicalResearch Center at Rush Medical CollegeChicago, IL

Reaching the goal


General hypertensive population reaching JNC VI goal of <130/85: <30%

Patients with diabetes and hypertension reaching JNC VI goal of <130/85: 11%

Patients with diabetes and hypertension reaching NKF goal of <130/80: ????

Critical issues


1) Team approach (physician, nurse clinician, nurse,

dietician)2) Timing of medication

(once daily dosing, fixed-dose combinations)

3) Education (What is the goal and why? Enlist the

patient as active participant.)


1) CME programs (classes of drugs and BP control)

2) Recertification (test them on recertification exam)

Physician outreach

Fear of a J-shaped curve


Fear is preventing the achievement of these goals:

1) No study with aggressive blood pressure control shows a J-shaped curve in cardiovascular events.

2) Fear of renal dysfunction is preventing adequate use of ACE inhibitors.

ACE-inhibitors and CCBs


In combination, these agents produce an additive reduction in blood pressure.

There is a reduction in the incidence of edema and proteinuria.

Adding a diuretic gives “more bang for your buck”.


How medical information is disseminated and how it is put forth have a huge impact on how the patient accepts the information.

Physicians must become aware that cultural factors impact treatment.

Socioeconomic factors


Hispanic community barriers:Language barrierMales reluctant to come inPreconceived notions about medication

Attempted solutions:Translators from the same cultureBuild confidence and trust“Shortcut approach” doesn’t work

Specific barriers


Diet and exercise go hand in hand with other approaches.

DASH study reduced BP in hypertensive subjects:

Systolic (mm Hg) -11.5 + 1.3Diastolic (mm Hg) -5.7 + 0.9

Lifestyle

Svetkey LP, et al. J Am Diet Assoc 1999; 99(s8): s96-104

Pocket guide


Pocket-sized version of treatment algorithm

Executive summary of the guidelines

National Kidney Foundation

1.800.622.9010

hypertension & diabetes: new guidelines janice douglas, md case western university cleveland, oh...

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