Naslov
Blood pressure management in type 2

Autori
Baretić, M

Vrsta, podvrsta i kategorija rada
Sažeci sa skupova, pp prezentacija, stručni

Izvornik
18th ESE Postgraduate Training Course on Endocrinology, Diabetes and Metabolism / - , 2016

Skup
18th ESE Postgraduate Training Course on Endocrinology, Diabetes and Metabolism

Mjesto i datum
Opatija, Hrvatska, 25.02.2016. - 28.02.2016

Vrsta sudjelovanja
Predavanje

Vrsta recenzije
Nije recenziran

Ključne riječi
hypertension; diabetes; therapy

Sažetak
Hypertension is an everyday issue for patients with both type 1 and type 2 diabetes mellitus. Since the treatment of hypertension in diabetic patients is associated with proven clinical benefits, there are few questions regarding the therapy that should be considered. What is the goal? Previous guidelines had suggested more intensive lowering of the blood pressure for diabetic patients. According to last guidelines by eighth Joint National Committee and the European Societies of Hypertension and Cardiology a common goal ofblood pressure, for both diabetic and non-diabetic population, is less than 140/90 mmHg. Though, there are also some subgroups in diabetes that must be considers. In patients with diabetic nephropathy and proteinuria a goal of blood pressure is less than 130/80 mmHg, and for those with type 2 diabetes plus either cardiovascular disease or at least two additional risk factors for cardiovascular disease the goal for systolic pressure is less than 120 mmHg. All lower values are expected only if they can be achieved without significant side effects. Who is the firs choice, who is the worst? It seems that the most prominent value ofthe antihypertensive drugs is their potency. The major determinant of lower cardiovascular risk is the grade of blood pressure reduction, not necessary the choice of antihypertensive drug class. So, the worst choice is better then none. While looking for the ideal antihypertensive drug some extra benefits beyond the blood pressure regulation are consider (prevention of mortality, adverse cardiovascular events and the progression of renal disease). In patients with increased albuminuria an ACE inhibitor (or ARB if unable to take an ACE inhibitor) is the first solutions. In patients without increased albuminuria, the choice of initial monotherapy is much wider (ACE inhibitor, ARB, thiazide diuretic or calcium channel blocker). Since rennin-angiotensin inhibitors have shown to reduce and prevent albuminuria the choice of them, even in patients without albuminuria, is common in everyday practice. Calcium channel blocker are very effective in lowering blood pressure, well tolerated, without adverse effects on lipid or carbohydrate metabolism. Some evidence from clinical trials with high doses of thiazide diuretic (including chlortalidone) confirmed their metabolic disadvantages. Later trials have shown that the increase in blood glucose is usually quite small with low-dose therapy, such small dosages are minimising the fall in plasma potassium and the rise in triglyceride and uric acid concentrations in diabetic patients. So they do not have to be the worst choice. Similar observations regarding antihypertensive therapy have beta blockers, though they have been recently downgraded as a first choice of therapy. Modest worsening of glycemic control in diabetic patients with an increased incidence of new onset diabetes was observed in older generations of beta blockers like metoprolol, and new generations like carvedilol seems to have advantages (potential benefits on glycemic control and lower rate of development of moderately increased albuminuria). Still, there are concerns about masking of hypoglycaemic symptoms and possible exacerbation of peripheral artery disease. How to combine? At the time type 2 diabetes is diagnosed, almost 40 % of patients are already hypertensive ; 70 % of those with type 1 diabetes at the age of 40 have hypertension. Measuring blood pressure must be routinely done by every visit, with attempt to add and/or adjust the therapy. For most of them during the time combination of two or more drug classes is finally required. There are many different combinations, but still, rennin-angiotensin inhibition is the basis of the antihypertensive combination therapy. In patients who require more than one drug to control their blood pressure, usual combination is an ACE inhibitor or ARB and a dihydropyridine calcium channel blocker, frequently in fixed combination. Small dose of thiazide diuretic, in fixed combination ACE inhibitor or an ARB too, are also commonly used. If adding beta blocker the choice is carvedilol.

Izvorni jezik
Engleski

Znanstvena područja
Kliničke medicinske znanosti

POVEZANOST RADA