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Antihypertensive Drugs Contraindicated In Diabetes

Changes In Treatment Of Hyperglycemia In A Hypertensive Type 2 Diabetes Population As Renal Function Declines

Changes In Treatment Of Hyperglycemia In A Hypertensive Type 2 Diabetes Population As Renal Function Declines

Despite continued efforts to control hemoglobin A1c (HbA1c) and an ever-expanding arsenal of new drugs [1], we may fall short of adequate control in a significant portion of patients with diabetes due to failure to recognize comorbidities [2]. As kidney disease progresses, clearance of oral agents such as glyburide, metformin or sitagliptan may be so diminished as to require discontinuation. The decrease in renal function due to acute kidney injury and chronic kidney disease (CKD) exacerbates fluid/volume overload, congestive heart failure, high blood pressure [3] as well as other comorbidities. Since there is little data focusing on the impact of renal dysfunction on these therapeutic choices, we examined the effect of renal (dys)function on the choice of antidiabetic medications. To understand the medication decisions in patients with both type 2 diabetes and hypertension, we evaluated the records of all patients seen at least twice during a sample 5-year period at Joslin Diabetes Center. This study was approved by the Committee on Human Studies of the Joslin Diabetes Center as a quality assurance study to determine adherence to quality guidelines. All patient records were anonymized and patient data deidentified prior to analysis. During this time 15 481 patients were seen more than twice and 10 540 individuals had diagnosis codes for both hypertension and diabetes. Of these 10 151 patients were identified as meeting these criteria with complete demographic information regarding height, weight, body mass index (BMI), estimated glomerular filtration rate (eGFR) and medication records available. There were 5623 men and 4528 women with a mean BMI of 31 kg/m2 (men 30, women 32), height 67 inches (69, 63), weight 198 lb (212, 182) and mean eGFR of 78 mL/min/1.73 m2 (78, 7 Continue reading >>

Blood Pressure, Diabetes And Diabetic Nephropathy - Em|consulte

Blood Pressure, Diabetes And Diabetic Nephropathy - Em|consulte

Blood pressure, diabetes and diabetic nephropathy F. Chantrel[1], B. Moulin[1], T. Hannedouche[1] [1]Department of Nephrology, Hpital Universitaire de Strasbourg, Strasbourg, France. Despite multiple evidence-based data that diabetic nephropathy is largely preventable and its progression slowed by currently available interventions diabetic patients are often undertreated, especially for the lowering of blood pressure. Recent studies, (HOT Syst-Eur, SHEP, UKPDS, CAPPP, ABCD, HOPE) have confirmed the efficiency of intensively treated blood pressure in reducing morbidity-mortality in this group of patients at high risk. Low blood pressure targets are mandatory, but may not be that easy to achieve, especially in the presence of renal failure. Early prescription of a combination of antihypertensive drugs is often neccessary. Thus, the clinical question relates to the best combination of drugs. Most studies in hypertensive diabetic patients have dealt with 3 classes of antihypertensives drugs: diuretics, beta-blockers and ACE-inhibitors. Diuretics are one of the most efficient hypotensive drugs available for treatment of hypertension in diabetic patients. Their use must be encouraged early in the stepped approach since diabetes is usually associated with mid-volume expansion due to hyperinsulinism and hyperadrenergic state. In spite of the proven benefit of beta-blockers in diabetic patients, these drugs are largely underused. The indications for selective beta-blockers should probably be broadened for most diabetic patients in primary prevention. Beta-blockers are essential in secondary prevention for patients with coronary artery disease and hypertension. ACE-inhibitors are now more and more widely prescribed in diabetic patients at all stages of hypertension and nephropat Continue reading >>

Which Antihypertensive Drugs Are Best For Patients With Type 2 Diabetes And Hypertension?

Which Antihypertensive Drugs Are Best For Patients With Type 2 Diabetes And Hypertension?

This article requires a subscription for full access. NEJM Journal Watch articles published within the last six months are available to subscribers only. Articles published more than 6 months ago are available to registered users. Continue reading >>

Drugs That Can Worsen Diabetes Control

Drugs That Can Worsen Diabetes Control

One of the main goals of any diabetes control regimen is keeping blood glucose levels in the near-normal range. The cornerstones of most plans to achieve that goal include following a healthy diet, getting regular exercise, and taking insulin or other medicines as necessary. However, it’s not uncommon for people with diabetes to have other medical conditions that also require taking medicines, and sometimes these drugs can interfere with efforts to control blood glucose. A few medicines, including some commonly prescribed to treat high blood pressure and heart disease, have even been implicated as the cause of some cases of diabetes. This article lists some of the medicines that can worsen blood glucose control, the reasons they have that effect, the usual magnitude of the blood glucose changes, as well as the pros and cons of using these drugs in people who have diabetes. Where the problems occur To understand how various medicines can worsen blood glucose control, it helps to understand how insulin, the hormone responsible for lowering blood glucose, works in the body. Insulin is released from the beta cells of the pancreas in response to rising levels of glucose in the bloodstream, rising levels of a hormone called GLP-1 (which is released from the intestines in response to glucose), and signals from the nerve connections to the pancreas. The secretion of insulin occurs in two phases: a rapid first phase and a delayed second phase. Both of these phases are dependent on levels of potassium and calcium in the pancreas. Insulin acts on three major organs: the liver, the muscles, and fat tissue. In the liver, insulin enhances the uptake of glucose and prevents the liver from forming new glucose, which it normally does to maintain fasting glucose levels. In muscle and f Continue reading >>

Controlling Hypertension In Patients With Diabetes

Controlling Hypertension In Patients With Diabetes

Hypertension and diabetes mellitus are common diseases in the United States. Patients with diabetes have a much higher rate of hypertension than would be expected in the general population. Regardless of the antihypertensive agent used, a reduction in blood pressure helps to prevent diabetic complications. Barring contraindications, angiotensin-converting enzyme inhibitors are considered first-line therapy in patients with diabetes and hypertension because of their well-established renal protective effects. Calcium channel blockers, low-dose diuretics, beta blockers, and alpha blockers have also been studied in this group. Most diabetic patients with hypertension require combination therapy to achieve optimal blood pressure goals. Nearly one in four adults in the United States has hypertension, and more than 10 million adults have diabetes.1 Moreover, hypertension is twice as common in persons with diabetes as it is in others.2 Obesity may be a common link between the two disorders, but other factors such as insulin resistance3 and autonomic dysfunction4 may also be involved. Excess weight with truncal obesity, hypertension, impaired glucose tolerance, insulin resistance, and dyslipidemia are among the components of the metabolic syndrome, which has been associated with an increased risk of coronary heart disease.5 In general, only 25 percent of patients with hypertension have adequate control of their blood pressure.6 Blood pressure goals are lower, and thus more difficult to achieve, in patients who also have diabetes. Elevated blood pressure is known to contribute to diabetic microvascular and macrovascular complications (Table 1).4,7,8 Fortunately, reductions in blood pressure can decrease the risk of these complications.8 TABLE 1 Microvascular complications Renal d Continue reading >>

Choice Of Antihypertensive Drug In The Diabetic Patient: Conclusion

Choice Of Antihypertensive Drug In The Diabetic Patient: Conclusion

Choice of Antihypertensive Drug in the Diabetic Patient Authors: H T Ong, FRCP, FAMM, FCCP, FACC ; J S Cheah, MBBS Hons, FRACP, FRCP This activity is intended for primary care physicians, endocrinologists, nephrologists, and cardiologists. The goal of this activity is to review the evidence for the optimum blood pressure control and best antihypertensive agents for patients with diabetes and apply this knowledge in treatment decisions. Upon completion of this activity, participants will be able to: Specify the target blood pressure for patients with hypertension and diabetes. Identify the most important factor in the prevention of clinical events in treating hypertension in diabetic patients. Specify the most significant outcome improved with renin-angiotensin antagonists in patients with diabetes and hypertension. Distinguish an appropriate first-line antihypertensive agent for patients with well-controlled diabetes. Identify an appropriate first-line antihypertensive agent for patients with poorly controlled diabetes. As an organization accredited by the ACCME, Medscape requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as "financial relationships in any amount, occurring within the past 12 months, that create a conflict of interest." Medscape encourages Authors to identify investigational products or off-label uses of products regulated by the U.S. Food and Drug Administration, at first mention and where appropriate in the content. Consultant Cardiologist, H T Ong Heart Clinic, Penang, Malaysia Disclosure: H. T. Ong, MBBS, M Med, FRCP, FAMM, FCCP, FACC, has disclosed no relevant financial relationship Continue reading >>

Diabetes With Hypertension

Diabetes With Hypertension

Patient professional reference Professional Reference articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use. You may find the Home and Ambulatory Blood Pressure Recording article more useful, or one of our other health articles. This article aims to provide a simple management plan for the management of people with diabetes mellitus who also have raised blood pressure (BP). It is based mainly on the current National Institute for Health and Care Excellence (NICE) recommendations. Patients with type 2 diabetes mellitus have a considerably higher risk of cardiovascular morbidity and mortality and are disproportionately affected by cardiovascular disease. Most of this excess risk is associated with high prevalence of well-established risk factors such as hypertension, dyslipidaemia and obesity in these patients.[1, 2]Hypertension plays a major role in the development and progression of microvascular and macrovascular disease in people with diabetes.[3] Early intervention and targeting multiple risk factors with both lifestyle and pharmacological strategies give the best chance of reducing macrovascular complications in the long term.[4] Antihypertensive therapies may promote the development of type 2 diabetes mellitus. Studies indicate that the use of angiotensin-converting enzyme (ACE) inhibitors and angiotensin-II receptor antagonists (AIIRAs) leads to less new-onset diabetes compared to beta-blockers, diuretics and placebo.[5] Epidemiology Hypertension is more prevalent in patients with type 2 diabetes than in those who don't have diabetes.[4] It is estimated that the prevalence of arterial hypertension (BP greater than 160/95 mm Hg) in patients with type 2 diabetes is in the Continue reading >>

Hypertension Drug Combination Contraindicated In Patients With Diabetes, Renal Impairment

Hypertension Drug Combination Contraindicated In Patients With Diabetes, Renal Impairment

Hypertension drug combination contraindicated in patients with diabetes, renal impairment The Food and Drug Administration (FDA) issued a warning for patients with type 2 diabetes or kidney (renal) impairment about possible risks when these patients use blood pressure medications containing aliskiren with other hypertension drugs called angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs). Preliminary data from a clinical trial shows that the drug combinations in patients with type 2 diabetes or renal impairment may increase the risks of kidney impairment, low blood pressure (hypotension), and high potassium blood levels (hyperkalemia). The data also showed a slight increase in cardiovascular events resulting in death or stroke; however, the FDA has reached no definite conclusion regarding an actual link between these drugs and death or stroke. Final trial results will be communicated once they become available. Aliskiren is a renin inhibitor used to treat high blood pressure. It is found in the following medications: Amturnide (aliskiren hemifumarate, amlodipine besylate, and hydrochlorothiazide), Tekturna (aliskiren hemifumarate), Tekurna HCT (aliskiren hemifumarate and hydrochlorothazide), Tekamio (ailskiren hemifumarate and amlodipine besylate), and Valturna (ailskiren hemifumarate and valsartan). In 2011, approximately 2.4 million prescriptions for aliskiren-containing products were dispensed to 451,000 patients in the United States. ACEIs include the brand names Altace, Lotensin, Zestril, and Zestoretic. ARBs include the brand names Atacand, Benicar, Micardis and Twynsta. The study from which the FDA is basing the new warning and contraindication is the Aliskiren Trial in Type 2 Diabetes Using Cardio-Renal Endpoints (ALTITUDE) Continue reading >>

Beta-blockers For The Treatment Of Hypertension In Patients With Diabetes: Exploring The Contraindication Myth

Beta-blockers For The Treatment Of Hypertension In Patients With Diabetes: Exploring The Contraindication Myth

, Volume 13, Issue5 , pp 435439 | Cite as Beta-blockers for the Treatment of Hypertension in Patients with Diabetes: Exploring the Contraindication Myth Purpose: To review the evidence supporting the contraindications (hypoglycemic unawareness, insulin resistance, and dyslipidemia) usually given as the reasons by physicians for not using beta blockers for treating hypertension in patients with diabetes mellitus. Methods: A research synthesis based on MEDLINE (January 1966 through January 1999), hand searches of pertinent references and textbooks, and consultation with experts. Results: There is little evidence to support the assertion that beta blockers should be routinely contraindicated in diabetes. Beta blockers have few clinically important effects on hypoglycemic awareness and recovery, insulin resistance and hyperglycemia, or lipid profiles. Moreover, when diabetics have been treated with beta blockers for hypertension or for the secondary prevention of myocardial infarction, they benefit as much, if not more, than nondiabetic patients. There may be many circumstances (e.g., hypertensive patients with coronary disease) under which beta blockers are the drugs of first choice for diabetic patients. Recommendations to use agents other than beta blockers (or low dose thiazide diuretics) for the treatment of hypertension in diabetes are based on these agents' effectiveness against surrogate endpoints, and not their proven benefit in preventing important clinical endpoints. Conclusions: Except for patients with brittle glycemic control, manifest hypoglycemic unawareness, renal parenchymal disease, or documented intolerance, beta blockers should no longer be considered routinely contraindicated in the presence of diabetes. hypertensiondiabetes mellitustreatmentbeta bloc Continue reading >>

Nine Drugs

Nine Drugs

I recently received an e-mail alerting me to a webpage discussing “9 Common Drugs That Every Diabetic Should Avoid Mixing With Their Meds.” It was such an intriguing title that I Googled the phrase, and found that several websites had exactly the same list I totally disagree with the author’s premise that people with diabetes (PWD) should avoid the medications on the list; in fact, all of these medications are reasonable for PWD to take, if their physician and/or pharmacist explains the issues involved. Here’s the original information (including some poor grammar and miscapitalizations), plus my comment for each: Beta Blockers: Beta-blockers, such as Lopressor (metoprolol), Tenormin (Atenolol), and Inderal (propanolol), have been known to reduce the release of insulin. The main concern for PWD with the use of beta-blockers, which are very useful drugs for the treatment of hypertension and heart disease, is that they might mask some of the symptoms of hypoglycemia. If you are prone to hypoglycemia, you could expect your usual symptoms relating to pounding heart and shakiness to be blunted while on beta-blockers. Minoxidil: Minoxidil, a direct vasodilator, has a tendency to raise blood glucose levels. See my comment after this list… Thiazide Diuretics: Thiazide diuretics include such drugs as Diuril (Chlorothiazide), Zaroxolyn (Metolazone), and Oretic (Hydrochlorothiazide), and is known to raise glucose levels due to its effect it has on causing the loss of potassium. See my comment after this list… Calcium channel blockers: Calcium channel blockers, which are prescribed for Hypertension, management of Angina include such drugs as Calan (Verapamil), Adalat (Nifedipine),and Norvasc (Amlodipine), and is known to reduce the secretion of insulin. I’m not sure wh Continue reading >>

Type 2 Diabetes: Blood Pressure Drugs May Be Harmful For Some Patients

Type 2 Diabetes: Blood Pressure Drugs May Be Harmful For Some Patients

Type 2 diabetes: blood pressure drugs may be harmful for some patients For some patients with type 2 diabetes, treatment with intense blood-lowering medication may do more harm than good. This is according to a new study published in The BMJ. For some patients with type 2 diabetes, antihypertensive medication may raise the risk of cardiovascular death. The researchers - including Mattias Brunstrm of the Department of Public Health and Clinical Medicine at Ume University in Sweden - found that antihypertensive drugs may increase the risk of cardiovascular death for diabetes patients with a systolic blood pressure under 140 mm/Hg. While almost 1 in 2 people in the US have high blood pressure , or hypertension , the condition affects around 2 in 3 Americans with diabetes, putting them at higher risk of stroke , heart disease and other cardiovascular problems. As such, people with diabetes are often prescribed medication to help lower blood pressure. The American Diabetes Association recommend a systolic blood pressure target of less than 140 mm/Hg for patients with type 2 diabetes - the most common form of diabetes - though a target of less than 130 mm/Hg is recommended for some patients, if it can be achieved safely. For their study, Brunstrm and his colleague Bo Carlberg, also of the Department of Public Health and Clinical Medicine at Ume, set out to investigate whether the effects of antihypertensive medication vary dependent on a patient's blood pressure prior to treatment. Increased cardiovascular death risk for some diabetes patients The team conducted a meta-analysis of 49 randomized controlled trials - involving a total of 73,738 participants - that looked at the cardiovascular outcomes of people with diabetes who were receiving blood pressure-lowering medication Continue reading >>

What Should Be The Antihypertensive Drug Of Choice In Diabetic Patients And Should We Avoid Drugs That Increase Glucose Levels? Pro And Cons.

What Should Be The Antihypertensive Drug Of Choice In Diabetic Patients And Should We Avoid Drugs That Increase Glucose Levels? Pro And Cons.

What should be the antihypertensive drug of choice in diabetic patients and should we avoid drugs that increase glucose levels? Pro and Cons. Munich Diabetes Research Group e.V., Munich Helmholtz Centre, Ingolstaedter Landstrasse 1, Munich-Neuherberg, Germany. [email protected] Diabetes Metab Res Rev. 2012 Dec;28 Suppl 2:60-6. doi: 10.1002/dmrr.2355. It has long been known that antihypertensive drugs may affect blood glucose in a differential manner. In particular new onset diabetes is significantly increased in association with the use of thiazides or beta-blockers, respectively, compared to placebo, whereas treatment with angiotensin-conversion-enzyme-inhibitors or angiotensin-receptor-blockers is associated with a lower than expected frequency, as also assessed in several meta-analyses. In line with these notions, the NAVIGATOR Trial was the first to report a significant preventive effect of an angiotensin-receptor-blocker on new onset diabetes evaluated as a primary outcome in a prospective randomized study. Hence, and in view of the fact that comparable blood pressure lowering with any of the five major classes of antihypertensive drugs, including calcium-channel-blockers, give comparable benefits in reducing cardiovascular complications, unless there are specific indications or contraindications for an individual drug, caution should be exercised, therefore, to use beta-blockers or thiazides as first-line drugs for blood pressure lowering indications in subjects at high risk to develop diabetes, especially in patients with so called metabolic syndrome. The potential of glycemic worsening in overt diabetic patients with thiazides or beta-blockers has less well been studied systematically, yet paradigmatically in UKPDS evaluating a randomized comp Continue reading >>

Treatment Of Hypertension In Adults With Diabetes

Treatment Of Hypertension In Adults With Diabetes

Hypertension (defined as a blood pressure ≥140/90 mmHg) is an extremely common comorbid condition in diabetes, affecting ∼20–60% of patients with diabetes, depending on obesity, ethnicity, and age. In type 2 diabetes, hypertension is often present as part of the metabolic syndrome of insulin resistance also including central obesity and dyslipidemia. In type 1 diabetes, hypertension may reflect the onset of diabetic nephropathy. Hypertension substantially increases the risk of both macrovascular and microvascular complications, including stroke, coronary artery disease, and peripheral vascular disease, retinopathy, nephropathy, and possibly neuropathy. In recent years, adequate data from well-designed randomized clinical trials have demonstrated the effectiveness of aggressive treatment of hypertension in reducing both types of diabetes complications. These recommendations are intended to apply to nonpregnant adults with type 1 or type 2 diabetes mellitus. Target audience These recommendations are intended for the use of health care professionals who care for patients with diabetes and hypertension, including specialist and primary care physicians, nurses and nurse practitioners, physicians’ assistants, educators, dietitians, and others. These recommendations are based on the American Diabetes Association Technical Review “Treatment of Diabetes in Adult Patients with Hypertension” (1). A technical review is a systematic review of the medical literature that has been peer-reviewed by the American Diabetes Association’s Professional Practice Committee. Evidence review: hypertension as a risk factor for complications of diabetes Diabetes increases the risk of coronary events twofold in men and fourfold in women. Part of this increase is due to the frequency o Continue reading >>

Blood Pressure Control In Type 2 Diabetic Patients

Blood Pressure Control In Type 2 Diabetic Patients

Abstract Diabetes mellitus (DM) and essential hypertension are common conditions that are frequently present together. Both are considered risk factors for cardiovascular disease and microvascular complications and therefore treatment of both conditions is essential. Many papers were published on blood pressure (BP) targets in diabetic patients, including several works published in the last 2 years. As a result, guidelines differ in their recommendations on BP targets in diabetic patients. The method by which to control hypertension, whether pharmacological or non-pharmacological, is also a matter of debate and has been extensively studied in the literature. In recent years, new medications were introduced for the treatment of DM, some of which also affect BP and the clinician treating hypertensive and diabetic patients should be familiar with these medications and their effect on BP. In this manuscript, we discuss the evidence supporting different BP targets in diabetics and review the various guidelines on this topic. In addition, we discuss the various options available for the treatment of hypertension in diabetics and the recommendations for a specific treatment over the other. Finally we briefly discuss the new diabetic drug classes and their influence on BP. Continue reading >>

Treatment Of Hypertension In Patients With Diabetes Mellitus

Treatment Of Hypertension In Patients With Diabetes Mellitus

INTRODUCTION AND PREVALENCE Hypertension is a common problem in patients with both type 1 and type 2 diabetes, but the time course in relation to the duration of diabetes is different [1-3]. Among those with type 1 diabetes, the incidence of hypertension rises from 5 percent at 10 years, to 33 percent at 20 years, and 70 percent at 40 years [1]. There is a close relation between the prevalence of hypertension and increasing albuminuria. The blood pressure typically begins to rise within the normal range at or within a few years after the onset of moderately increased albuminuria (the new term for what was previously called "microalbuminuria") [2] and increases progressively as the renal disease progresses. (See "Moderately increased albuminuria (microalbuminuria) in type 1 diabetes mellitus", section on 'Risk factors'.) These features were illustrated in a study of 981 patients who had type 1 diabetes for five or more years [3]. Hypertension was present in 19 percent of patients with normoalbuminuria, 30 percent with moderately increased albuminuria, and 65 percent with severely increased albuminuria (the new term for what was previously called "macroalbuminuria") [2]. The incidence of hypertension eventually reaches 75 to 85 percent in patients with progressive diabetic nephropathy [4]. The risk of hypertension is highest in blacks, who are also at much greater risk for renal failure due to diabetic nephropathy. (See "Overview of diabetic nephropathy".) The findings are different in patients with type 2 diabetes. In a series of over 3500 newly diagnosed patients, 39 percent were already hypertensive [5]. In approximately one-half of these patients, the elevation in blood pressure occurred before the onset of moderately increased albuminuria. Hypertension was strongly a Continue reading >>

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