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Hypertension Algorithmfor Diabetes in Adults

BP 130/80 mmHg BP>130/80 mmHg

Follow-up BP each visit

If microalbuminuria or nephropathypresent (Table 1)

Continue Therapy

BP Check Every Visit

Footnotes1 Joint National Committee on Detection, Evaluation and Treatment of High

Blood Pressure: The seventh report of the Joint National Committee onDetection, Evaluation and Treatment of High Blood Pressure (JNC 7). JAMA.2003;289(19):2560-72; consider secondary causes as appropriate

2 Maintain non-pharmacological therapy throughout treatment. MedicalNutrition Therapy Algorithm + low sodium diet (130/80 mmHg

BP 130/80 mmHg BP>130/80 mmHg

Refer to Specialist (Endocrinologist or Nephrologist)OR

ADD:a blocker, hydralazine, clonidine (caution with b blocker)

***Alternative treatmentBP >130/80 mmHg despite above agents or

if intolerance/contraindications exist:

ADD: Medication not chosen from above

OR Go to Alternative Treatment***

Revised 1/26/12Publication # 45-11267

1 of 2 Hypertension Algorithm for Diabetes in Adul ts Revised 1/26/12 See disclaimer at www.tdctoolkit.org/algorithms_and_guidelines.asp

D i a b e t e s t r e a t m e n t a l g o r i t h m s

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Proper blood preure aementNational Committee on Detection, Evaluation and Treatmentof High Blood Pressure: The Seventh Report of the Joint NationalCommittee on Detection, Evaluation and Treatment of High BloodPressure (JNC 7). National Institutes of Health, National Heart,

Lung and Blood Institute, 2003 http://www.nhlbi.nih.gov/guidelines/hypertension/

ACE inhibitor a 1st line therapy in Diabete MellituNational Committee on Detection, Evaluation and Treatmentof High Blood Pressure: The Seventh Report of the Joint NationalCommittee on Detection, Evaluation and Treatment of High BloodPressure (JNC 7). National Institutes of Health, National Heart,Lung and Blood Institute, 2003 http://www.nhlbi.nih.gov/guidelines/hypertension/

Kasiske BL, Kalil RS, Ma JZ, et al.: Effect of antihypertensivetherapy on the kidney in patients with diabetes: a meta-regressionanalysis.Ann Intern Med118:12938, 1993

UK Prospective Diabetes Study Group: Efficacy of atenolol andcaptopril in reducing the risk of macrovascular complications intype 2 diabetes (UKPDS 39) BMJ317:71320, 1998

The Heart Outcomes Prevention Evaluation Study. Effects ofan ACE inhibitor, ramipril, on cardiovascular events in high riskpatients. N Engl J Med342:14553, 2000

Pahor M, Psaty BM, Alderman MH, et al. Therapeutic benefits ofACE inhibitors and other antihypertensive drugs in patients withtype 2 diabetes. Diabetes Care23:888-92, 2000

Wing LMH, Reid CM, Ryan P, et al. A comparison of outcomeswith angiotensin-converting-enzyme inhibitors and diuretics forhypertension in the elderly (ANBP2). N Engl J Med348:583-92,2003

Diuretic a econd lineNational Committee on Detection, Evaluation and Treatmentof High Blood Pressure: The Seventh Report of the Joint NationalCommittee on Detection, Evaluation and Treatment of High BloodPressure (JNC 7). National Institutes of Health, National Heart,Lung and Blood Institute, 2003http://www.nhlbi.nih.gov/guidelines/hypertension/

Antihypertensive & Lipid Lowering Treatment to Prevent HeartAttack (ALLHAT)JAMA 288:2981-97, 2002

Beta-Blocker a econd lineNational Committee on Detection, Evaluation and Treatmentof High Blood Pressure: The Seventh Report of the Joint NationalCommittee on Detection, Evaluation and Treatment of High BloodPressure (JNC 7). National Institutes of Health, National Heart,

Lung and Blood Institute, 2003http://www.nhlbi.nih.gov/guidelines/hypertension/

UK Prospective Diabetes Study Group: Efficacy of atenolol andcaptopril in reducing the risk of macrovascular complications intype 2 diabetes(UKPDS 39) BMJ 317:71320, 1998

Hansson L, Lindholm LH, Niskanen L, et al. Effect ofangiotensin converting-enzyme inhibition compared withconventional therapy on cardiovascular morbidity and mortalityin hypertension: the Captopril Prevention Project (CAPPP)randomised trial. Lancet353: 61116, 1999

Verapamil or Diltiazem

Hansson L, Hedner T, Lund-Johansen P, et al. Randomizedtrial of effects of ca lcium antagonists compared with diureticsand beta-blockers on cardiovascular morbidity and mortality inhypertension. NORDIL. Lancet356:35965, 2000

Bakris GL, Copley JB, Vicknair N, et al. Calcium channelblockers versus other antihypertensive therapies on progression ofNIDDM associated nephropathy.Kidney Int50:164150, 1996

Dihydropyridine calciumchannel blockerTuomilehto J, Rastenyte D, Birkenhager WH, et a l. Effect ofcalcium channel blockage in older patients with diabetes andsystolic hypertension. N Engl J Med 340:67784, 1999

Dahlof B, Sever P, Poulter N, et al. Prevention of cardiovascularevents with an antihypertensive regimen of amlodipineadding perindopril as required versus atenolol addingbendroflumethiazide as required, in the Anglo-ScandinavianCardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial. Lancet 366:895-906, 2005

Estacio RO, Jeffers BW, Hiatt WR, et al. The effect of nisoldipineas compared with enalapril on cardiovascular outcomes inpatients with non-insulin-dependent diabetes and hypertension.N Engl J Med338:64552, 1998

Alpha-BlockerMajor cardiovascular events in hypertensive patients randomizedto doxazosin vs chlorthalidone. (ALLHAT Data)JAMA283:196775, 2000

Blood Preure Goal 1 gram/ 24 hour BP goal