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Why Are Ace Inhibitors The Drug Of Choice In Diabetic Patients With Hypertension?

Ace Inhibitors In Type 2 Diabetes With Hypertension - General Practice Notebook

Ace Inhibitors In Type 2 Diabetes With Hypertension - General Practice Notebook

ACE inhibitors in type 2 diabetes with hypertension The role of ACE inhibitors in patients with diabetics has been investigated in the studies such as the: the HOPE study (n=9,297, 38% with diabetes) provided evidence that ramipril significantly reduced the risk of MI, stroke or cardiovascular death compared with placebo over five years (14.0% vs. 17.8%; NNT 27) - benefits were especially evident in the subgroup of patients with diabetes it has been suggested that these effects of ramipril are beyond those that could be expected from its BP lowering properties - however, this has been disputed by meta-analyses that suggest, for most cardiovascular outcomes, BP lowering effects account for the majority of the benefits seen with different antihypertensives (1) ACE inhibitors slow the progression of renal disease in type I diabetes independent of the effects of blood pressure. There is mounting evidence that the same is true in type II diabetes. The benefits of treatment with ACE inhibitors may result from reducing proteinuria and reducing blood pressure (these effects are not specific to ACE inhibitors) and via direct effects of angiotensin II on glomerular haemodynamics, inflammation, slcerosis and fibrosis (3). Note it has been suggested that thiazide diuretics should be the first-line treatment for diabetic patients with hypertension based on study evidence such as ALLHAT (2) (see linked item): "..Thiazide diuretics are a suitable first choice in people with type 2 diabetes. ACE inhibitors are a reasonable alternative to a thiazide if these are unsuitable, or addition to a thiazide if further BP lowering is required. ACE inhibitors should be used first-line in people with type 2 diabetes if they have renal disease..." A meta-analysis of the use of angiotensin receptor Continue reading >>

Ace Inhibitors Top Choice For Hypertension In Diabetes

Ace Inhibitors Top Choice For Hypertension In Diabetes

ACE Inhibitors Top Choice for Hypertension in Diabetes As recommended in guidelines, angiotensin-converting enzyme (ACE) inhibitors should be the first-line treatment in patients with hypertension who have diabetes mellitus (DM) when cost is not a concern, according to a new study. In addition, the authors suggest that calcium channel blockers might be the preferred treatment in combination with ACE inhibitors if adequate blood pressure control cannot be achieved by ACE inhibitors alone. Among patients with DM, ACE inhibitors fared better than placebo in reducing creatinine doubling, and beta-blockers were associated with an increased risk of death. In addition, ACE inhibitors in combination with other antihypertension medications did not show significant protective effects compared with placebo, but the likelihood of lowering mortality in patients was greater. Guidelines suggest ACE inhibitors or angiotensin receptor blockers (ARBs) should be the first-line treatment in in patients with hypertension who have DM when cost is not a concern. Clinical trials comparing an ACE inhibitor with an ARB are rare, and the difference in protective effects between these drugs for patients with DM remains inconclusive. No consensus exists about the choice of treatments in combination with renin-angiotensin system blockers in patients with DM, state lead author Hon-Yen Wu and colleagues from National Taiwan University Hospital and College of Medicine, Taipei, Taiwan. By combining direct and indirect evidence, our analyses show the renoprotective effects and superiority of ACE inhibitors in patients with diabetes, and also show the harmful effects of beta-blockers, the authors state. As the available evidence is not able to show a better protective effect for ARBs compared with ACE in Continue reading >>

Ace Inhibitors

Ace Inhibitors

A class of medicine usually used to treat high blood pressure. Angiotensin-converting enzyme (ACE) inhibitors also appear to protect people with diabetes from diabetic nephropathy (kidney disease). People with diabetes are especially prone to hypertension (defined as a blood pressure level of 140/90 mm Hg or greater). Some 20% to 60% of individuals with diabetes have high blood pressure. Hypertension increases their risk not only of heart disease and stroke, but also of peripheral vascular disease, diabetic retinopathy, diabetic nephropathy, and possibly diabetic neuropathy. The American Diabetes Association (ADA) currently recommends a target blood pressure level of under 130/80 mm Hg in people with diabetes. The ADA recommends a number of different measures for lowering blood pressure, including weight loss, sodium restriction, and exercise. When these measures aren’t enough, the addition of one or more medicines is warranted. There are several different classes of blood pressure drugs, including angiotensin-receptor blockers (ARBs), diuretics, beta blockers, and ACE inhibitors. Overall, drug therapy has been shown to substantially decrease the risk of cardiovascular disease, diabetic retinopathy, and diabetic nephropathy. ACE inhibitors may have a special advantage in terms of slowing the progression of diabetic nephropathy. Research findings show that ACE inhibitors can slow the progression of kidney disease to a greater degree than other antihypertensive drugs that lower blood pressure by a similar amount and that they may be able to protect the kidneys even in people with diabetes whose blood pressure levels are in the normal range. This suggests that ACE inhibitors protect the kidneys by mechanisms other than just blood pressure control. Currently, the ADA reco Continue reading >>

Pharm Exam 5 Flashcards | Quizlet

Pharm Exam 5 Flashcards | Quizlet

What assessments should be made before prescribing any antihypertensive agent? BP (confirmation of elevated BP at three different times), & head to toe assessment LABS: electrolytes (Na and K level; serum Ca); blood glucose and hematocrit; Lipid profile; Renal function (creatinine and BUN levels); urinalysis, albumin or albumin/creatinine ratio. children >3yrs should be assessed @ least once at every visit - preferred method for children is by auscultation, using a cuff that is appropriate to the child's upper arm. diabetics or those with renal disease should have the albumin/creatinine ratio annually. Presence of albuminuria, micro albuminuria even in the setting of normal glomerular filtration rate is associated with increased cardiovascular risk Why are ACE inhibitors the drug of choice in diabetic patients with hypertension? ACE inhibitors will improve insulin's sensitivity; as well as reduce the effects of diabetes on the kidneys "Protect the Kidney's" - watch for renal function, any creatinine > 2.5 requires dose reduction! Prevents diabetic nephropathy or slow its progression, ACE or ARBs should be used to treat the HTN. Renal protection; reduces the conversion of AT II and improve the insulin sensitivity ACE inhibitors are a central part of the treatment of heart failure because they have more than one action to address the pathological changes in this disorder. Which of the following pathological changes in heart failure is NOT addressed by ACE inhibitors? Activation of the sympathetic nervous system that increases heart rate and preload. Heart failure is a leading cause of death and hospitalization in older adults (greater than 65 years old). The drug of choice for this population is: ACE inhibitors are contraindicated in pregnancy. While treatment of heart f 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 >>

Prevention And Treatment Of Diabetic Renal Disease In Type 2 Diabetes: The Benedict Study

Prevention And Treatment Of Diabetic Renal Disease In Type 2 Diabetes: The Benedict Study

Abstract Diabetic nephropathy (DN) is the leading cause of end-stage renal failure in Western countries and carries an increased risk for cardiovascular mortality. Studies have identified a number of factors that play a part in the development of DN. Among them, hypertension and proteinuria are the most important. In the early stages of DN, when albumin is present in the urine in very low quantities (microalbuminuria) and an increase is seen in BP, there is no loss of filtrate and patients respond well to prophylactic measures. Microalbuminuria is considered an early marker of DN. Prevention of the onset of microalbuminuria, therefore, could be considered as the primary means of preventing DN. The Bergamo Nephrologic Diabetes Complication Trial (BENEDICT) was a prospective, randomized, double-blind, parallel-group study that was organized in two phases. Phase A included 1204 patients and was aimed at assessing the efficacy of the angiotensin-converting enzyme (ACE) inhibitor trandolapril, the non-dihydropyridine calcium channel blocker verapamil, and the trandolapril plus verapamil combination as compared with placebo in prevention of microalbuminuria in hypertensive patients with type 2 diabetes and normal urinary albumin excretion rate. Phase B was aimed at assessing the efficacy of the combination as compared with trandolapril alone in prevention of macroalbuminuria in patients with microalbuminuria. The BENEDICT Phase A study showed that DN can be prevented by ACE inhibitor therapy. The beneficial effect of ACE inhibition is not enhanced by combined non-dihydropyridine calcium channel blocker therapy. The apparent advantage of ACE inhibitors over other agents includes a protective effect on the kidney against the development of microalbuminuria, which is a major ris Continue reading >>

Chapter 7. Hypertension Complicated By Other Diseases

Chapter 7. Hypertension Complicated By Other Diseases

Chapter 7. Hypertension complicated by other diseases Hypertension Research volume 32, pages 5156 (2009) The target of blood pressure control in hypertension complicated with diabetes mellitus should be <130/80 mm Hg. When selecting antihypertensive drugs for diabetic hypertensive patients, an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) is recommended as the first choice because of the positive effects on glucose and lipid metabolism and for the prevention of complications, and a Ca blocker and low-dose of thiazide diuretic should be used concomitantly for blood pressure control. When hypertension is complicated with angina on effort or old myocardial infarction, -blockers, which have a cardioprotective effect, can also be used for blood pressure control. When selecting antihypertensive drugs for hypertension with dyslipidemia, -blockers, ACE inhibitors, Ca channel blockers, and ARBs that improve or do not exacerbate lipid metabolism are considered appropriate. In diabetic patients, blood pressure should be measured in both a recumbent and standing as well as a sitting position, because orthostatic hypotension is observed in some patients. The frequency of hypertension is about two times higher in diabetic than in nondiabetic individuals according to results in Japan.477 In addition, the frequency of diabetes mellitus is two to three times higher in hypertensive patients,477 and an etiological relationship between the two diseases has been suggested, that is, type II diabetes and hypertension are major factors of metabolic syndrome (discussed later), having insulin resistance as a common background factor. Microvascular complications of diabetes mellitus include nephropathy, neuropathy and retinopathy. These conditions may not 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 >>

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 >>

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 >>

Role Of Ace Inhibitors In Treating Hypertensive Diabetic Patients.

Role Of Ace Inhibitors In Treating Hypertensive Diabetic Patients.

Role of ACE inhibitors in treating hypertensive diabetic patients. Department of Endocrinology, Diabetes and Hypertension, SUNY Health Science Center at Brooklyn, 450 Clarkson Avenue, Box 1205, Brooklyn, NY 11203, USA. Cardiovascular disease (CVD) is a major determining factor of morbidity and mortality in type 2 diabetic patients. Hypertension, which accompanies diabetes in more than 70% of cases, contributes to increased prevalence of CVD events in this group of patients. Results from the United Kingdom Prospective Diabetes Study (UKPDS) indicated that reduction of elevated blood pressure might decrease CVD morbidity and mortality more than reduction of hyperglycemia. Activation of circulating and tissue renin-angiotensin system (RAS) contributes to the development of both hypertension and insulin resistance in patients with the cardiometabolic syndrome. Angiotensin-converting enzyme (ACE) inhibitor therapy in patients with the cardiometabolic syndrome may improve insulin action as well as lessen CVD. In clinical trials, ACE inhibitors have been shown to be more efficient than other antihypertensive medications (i.e., calcium channel blockers) in the reduction of CVD morbidity and mortality in hypertensive diabetics. In this article, we summarize possible mechanisms by which ACE inhibition may improve insulin resistance, coagulation/clotting, and vascular function abnormalities, and postpone or even prevent the development of type 2 diabetes in hypertensive patients. Continue reading >>

Management Of Hypertension In The Diabetic Patient.

Management Of Hypertension In The Diabetic Patient.

Management of hypertension in the diabetic patient. Department of Allergy and Immunology, University of Wisconsin Hospital and Clinics, Madison 53705. Therapeutic considerations regarding the treatment of hypertension in patients with diabetes mellitus are reviewed. Good blood pressure control is essential in diabetic patients to prevent morbidity and mortality associated with cardiovascular diseases. Hypertension may also accelerate complications of diabetic microvascular disease, nephropathy, and retinopathy. Diuretics (e.g., thiazides, furosemide, ethacrynic acid, bumetanide) and beta blockers have traditionally been used as initial therapy for most patients with hypertension; however, these agents may not be the best choice for diabetics. Adverse metabolic consequences include alteration of glucose metabolism and plasma lipids. Beta blockers may also blunt the ability of patients to recognize symptoms of hypoglycemia. Both diuretics and beta blockers can cause sexual dysfunction in men. Adrenergic agents and vasodilators are associated with a high prevalence of orthostatic hypotension in diabetic patients. The calcium-channel blockers are considered safe and well tolerated when given at low and moderate doses. The angiotensin-converting-enzyme (ACE) inhibitors are able to slow the progression of diabetic nephropathy by reducing the glomerular hypertension that causes it. For the treatment of mild hypertension in diabetic patients, the drugs of choice should include (in descending order) ACE inhibitors, calcium-channel blockers, diuretics, and beta blockers. Severe or resistant hypertension usually requires treatment with combinations of drugs, including a diuretic. Tailoring therapy to individual complications and close monitoring of the patient are essential for s Continue reading >>

Treatment Of Hypertension In Type 2 Diabetes Mellitus: Blood Pressure Goals, Choice Of Agents, And Setting Priorities In Diabetes Care Free

Treatment Of Hypertension In Type 2 Diabetes Mellitus: Blood Pressure Goals, Choice Of Agents, And Setting Priorities In Diabetes Care Free

Abstract Background: Hypertension in patients with type 2 diabetes mellitus is a prevalent condition that leads to substantial morbidity and mortality. Purpose: To evaluate the goals and optimal agents for treatment of hypertension in type 2 diabetes. Study Selection: Randomized trials that evaluated the pharmacologic treatment of hypertension in patients with diabetes and reported microvascular and macrovascular outcomes. Data Extraction: Studies were identified by using the Cochrane Library, MEDLINE, meta-analyses, review articles, and expert recommendation. The searches of the Cochrane Library and MEDLINE were performed in May 2000 and updated in April 2002. Data were abstracted to standardized forms by a single reviewer and were confirmed by a second reviewer. Data Synthesis: Treatment of hypertension in type 2 diabetes provides dramatic benefit. Target diastolic blood pressures of less than 80 mm Hg appear optimal; systolic targets have not been as rigorously evaluated, but targets of 135 mm Hg or less are reasonable. Studies that compare drug classes do not suggest obviously superior agents. However, it is reasonable to conclude that thiazide diuretics, angiotensin-II receptor blockers, and perhaps angiotensin-converting enzyme (ACE) inhibitors may be the preferred first-line agents for treatment of hypertension in diabetes. -Blockers and calcium-channel blockers are more effective than placebo, but they may not be as effective as diuretics, angiotensin-II receptor blockers, or ACE inhibitors; however, study results are inconsistent in this regard. Conclusions: Treatment of hypertension in type 2 diabetes, with blood pressure goals of 135/80 mm Hg, provides dramatic benefits. Thiazide diuretics, angiotensin II receptor blockers, and ACE inhibitors may be the best Continue reading >>

Management Of Blood Pressure In Patients With Diabetes

Management Of Blood Pressure In Patients With Diabetes

Management of Blood Pressure in Patients With Diabetes Department of Internal Medicine D and Hypertension unit, The Chaim Sheba Medical Center, Tel-Hashomer, affiliated to Sackler Faculty of Medicine, Tel-Aviv University Division of Cardiology, Luke's-Roosevelt Hospital and Columbia University American Journal of Hypertension, Volume 24, Issue 8, 1 August 2011, Pages 863875, Ehud Grossman, Franz H. Messerli; Management of Blood Pressure in Patients With Diabetes, American Journal of Hypertension, Volume 24, Issue 8, 1 August 2011, Pages 863875, Hypertension is a major modifiable risk factor for cardiovascular morbidity and mortality in patients with diabetes. Lowering blood pressure (BP) to 135/85 mmHg is the main goal of treatment. A nonpharmcologic approach is recommended in all patients. If BP levels remain above the target despite nonpharmacologic treatment, drug therapy should be initiated. Blockers of the reninangiotensinaldosterone system (RAAS) represent the cornerstone of the antihypertensive drug arsenal; however, in most patients, combination therapy is required. For many patients, a combination of RAAS blocker and calcium antagonist is the combination preferred by the treating physician. Often three or even four drugs are needed. Treatment should be individualized according to concomitant risk factors and diseases and depending on the age and hemodynamic and laboratory parameters of the patient. In order to maximally reduce cardio renal risk, control of lipid and glycemic levels should also be ensured. American Journal of Hypertension, advance online publication 28 April 2011; doi:10.1038/ajh.2011.77 blood pressure , diabetes mellitus , hypertension , treatment Hypertension is a powerful risk factor for cardiovascular morbidity and mortality, 1 particuarly Continue reading >>

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