Her problem of Hypertension was diagnosed almost 6 years ago when her blood pressure remained consistently on the higher side on 4 consecutive visits to the clinic. It was consistently high in the range of 160/90 mmHg.
Almost a year ago, she was also detected with microalbuminuria during her annual screening of urine. At that time, 1,943 mg/dl of microalbumin was detected in her urine sample.
Subjective
She has come to the clinic today for her regular checkup and follows up visit for the diabetes and hypertension. She is a house wife. And has three children.
Objective
She got an initial treatment for her diabetes which consisted of sulfonylurea along with the rapid addition of metformin. The most recent examination showed that her diabetes has been fairly controlled with hemoglobin A1c of 7.4%.
Her initial treatment for the hypertension was lisinopril, starting at 10 mg daily which slowly increased to 20mg daily dose. But her control of BP has been fluctuated.
Discussion questions
- What is type 2 diabetes Mellitus?
- What is hypertension?
- What effects are placed when the BP is controlled in the patients having diabetes?
- Which target BP should be maintained for the patients having diabetes and hypertension?
- What are the recommended antihypertensive agents for the patients having diabetes?
Commentary
- What is type 2 diabetes Mellitus?
It is one of the most common forms of diabetes. When the body fails to produce insulin or is unable to produce enough amount of insulin, it results in type . Insulin is vital for the body as it enables the body to use glucose for the energy. When we take in food, the body breaks down all the sugar and starch in it into glucose, which provides the basic fuels to the cells of the body. Insulin helps the cells to absorb glucose from the blood. So the diabetes complication results when the cells are unable to take up sugar from the blood and the sugar level in the blood rises (Type2, 2013).
Diabetes is one of the major risk factors for a number of heart diseases. Approximately half of the middle aged patients with diabetes have shown evidences of coronary artery disease (CAD) as compared with the patients who don’t have diabetes.
A number of risk factors for cardiovascular diseases (CVD) are present in the diabetic patients such as hypertension dyslipidemia, and a sedentary lifestyle. These are particularly relevant to the patients with diabetes. Among the patients with diabetes to reduce CVD mortality and morbidity, aggressive glycemic treatment control along with other CVD factors needs to be initiated.
- What is hypertension?
Hypertension means a high blood pressure. The condition in which the arteries maintain persistently high levels of blood pressure is referred to as hypertension. The higher rates of blood pressure mean that the heart has to work and pump harder than the normal. Hypertension can cause damage to the heart and other organs as well as several other diseases such as failure of kidneys, heart attack or heart failure.
- What effects are placed when the BP is controlled in the patients having diabetes?
Various studies have been done to find what effects are placed when the BP is controlled in the patients having diabetes. A number of studies have shown reduction in CVD event when antihypertensive treatment in patients with diabetes has been compared with placebo. In a study conducted by United Kingdom Prospective Diabetes Study (UKPDS), patients with diabetes were followed for an average of 8.5 years. It was found in the study that patients having tight BP control (< 150/< 85 mmHg) versus less tight control (< 180/< 105 mmHg), had shown lower rates of myocardial infarction (MI), stroke, and peripheral vascular events (U.K. Prospective Diabetes Study Group,1998) . Following this prospective study, many studies were conducted to find the effect of tight BP control on the initial level of the type 2 diabetes.
A study conducted by Holman, Paul, Bethel, et al.(2008) studied the 5102 patients from the UKDPS patients. Those patients were recently diagnosed with type 2 diabetes. The results of the study showed that the effect of the tight blood pressure controls on 2 groups. There were significant reductions in the diabetes related death, microvascular disease and the stroke in the group which received tight blood pressure control as compared to the group that received relatively lighter BP control.
Another study was conducted on 5102 patients, who were newly diagnosed with type 2 diabetes. Out of these 4209 were either given conventional therapy (dietary restriction) or intensive therapy ( sulfonylurea or insulin or,metformin in the patients who were overweight) to control the glucose levels. They were asked to attend UKPDS clinics for 5 years, annually but they were not asked to maintain their previously assigned therapies. The differences in the glycated hemoglobin levels between the groups were finished after the first year. In the group who were assigned to intensive therapy there was a continued reduction in risk factors for microvascular risk myocardial infarction and death in the follow-up for 10 years. The metformin therapy had continuous effect on the patients who were overweight (Holman,Sanjoy, et al.,2008).
- Which target BP should be maintained for the patients having diabetes and hypertension?
Many different types of medications and drugs has been used for the treatment of BP. It has been observed that all classes of drugs have been useful lowering the mortality rate and morbidity rates in the patients. In many of the cases, numerous agents are required for the achievement of a certain level of BP. Studies showed that administration of almost any kind of drug therapy in diabetic patients has been found to be effective in decreasing the risks of cardiovascular diseases. So while treating the diabetic patients with hypertension, numerous agents often numerous agents are required to achieve the required controlled BP levels.
A study was conducted to find the target blood pressure in the diabetic patients having hypertension. The study accumulated the evidence gathered from the other studies done on the topic till 2011. The results of the meta-analysis showed that the new set goal for the patients with type 2 diabetes should be 130–135 mmHg systolic blood pressure (Nilsson, 2011).
Another study explored the effect of trandolapril/verapamil combination in managing hypertension in the patients having diabetes. The study results, showed that trandolapril plus verapamil or trandolapril alone caused a delay in the onset of microalbuminuria independent in the diabetic patients independent of their blood pressure-reducing effect. This shows that trandolapril/verapamil is an effective option for the treatment of hypertensive diabetic patients who require more than one agent for the achievement of their target blood pressure (Sharma, Ruggenenti & Remuzzi,2011).
- What are the recommended anti-hypertensive agents for the patients having diabetes?
A study conducted to find the choice of antihypertensive drugs in the treatment of diabetic patients showed that diuretics, beta-blockers, calcium channel blockers (CCBs), angiotensin-converting enzyme (ACE) inhibitors, and the angiotensin-receptor antagonists (ARBs) , all help in the successful reduction of the adverse effects. The trials with hypertensive drugs, Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) showed that diuretic place a better hypotensive effect as compared to that of CCBs and ACE inhibitors. In Valsartan Antihypertensive Long-term Use Evaluation (VALUE) trial, also showed good control of blood pressure. Diuretics should form the any hypotensive treatment plan for most of the diabetic patients as it showed effective clinical advantages.
It is required with most of the hypertensive diabetic patients that a combination of antihypertensive drugs should be used to achieve the blood pressure control of under 130/80 mm Hg (Ong & Cheah,2005).
Treatment options for patient
The case of Lenny is that of typical patient having obesity, hypertension along with diabetes. Her control over the BP needs to be improved. For achieving the target BP of < 130/80 mmHg it may be important to maximize the dose of ACE inhibitors along with adding second or third agent if needed. Her treatment will be based on the individual assessment and needs. With the addition of beta- blockers with that of Ace-inhibitors, will definitely lower her BP and will also help to reduce the morbidity of cardiovascular diseases. Another option is to reduce BP and diabetic progression is to use combination of ARBs and ACE inhibitors because of the presence of microalbuminuria.
Thus, overall an aggressive treatment will be needed to control the BP of Lenny along with diabetes in the light of recent trials and emerging new pharmacological agents.
References
Holman,R.R., Sanjoy K. P., Bethel,M.A., Matthews,D.R. and Neil, H.A.W.(2008). 10-Year Follow-up of Intensive Glucose Control in Type 2 Diabetes. The New English Journal of Medicine. Vol. 359:1577-1589.
Holman,R.R., Sanjoy K.P., Bethel, M.A. H., et al.(2008). Long-Term Follow-up after Tight Control of Blood Pressure in Type 2 Diabetes. The New English Journal of Medicine.Vol.359:1565-1576.
Ong, H.T. & Cheah, J.S.(2005). Choice of antihypertensive drug in the diabetic patient.
Med Gen Med. May 4;7(2):74.
Nilsson,P.(2011). Target blood pressure in diabetes patients with hypertension—What is the accumulated evidence in 2011?. Journal of Zhejiang University. Science. B. August;12(8); 611-623.
Sharma,S.K., Ruggenenti, P. & Remuzzi,G. (2007). Managing hypertension in diabetic patients – focus on trandolapril/verapamil combination. VAS health Risk Management.August; 3(4): 453-465.
Type 2. (2013). American Diabetes Association. Retrieved on 27 May 2013 from http://www.diabetes.org/diabetes-basics/type-2/
U.K. Prospective Diabetes Study Group.(1998). Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes. UKPDS. BMJ 317:713 -720.
