Management of hypertension in Type 2 diabetes mellitus

• 1st choice

In younger patients ( < 55yr) , Non-black and patients with nephropathy , use long-acting ACE inhibitors and only if ACE inhibitor is not tolerated, A2 antagonists as first line agents particularly in the presence of nephropathy or heart failure.
Check U&E before and 1 week after initiating therapy. Stop ACE inhibitor or A2 antagonist if creatinine rises or potassium >5.

Use Bendrofluazide 2.5mg OD in the elderly ( >55yr) and Afrocaribbean populations where ACE inhibitors are less effective

• 2nd choice

In younger patients add Bendrofluazide 2.5mg OD if target blood pressure not achieved on optimal doses of ACE inhibitors as Bendrofluazide acts synergistically with ACE inhibitors/ A2 antagonists to further reduce blood pressure. Consider Indapamide 1.5 mg OD if lipids adversely affected.

In patients with nephropathy consider Verapamil or Diltiazem as second choice if nephropathy and Bendrofluazide as 3rd choice in this instance. Also consider long-acting calcium channel blockers as second choice in Afrocaribbean patients.

In elderly add ACE inhibitors and only if not tolerated A2.

• 3rd choice

Add other agents as necessary to achieve target blood pressure

• ß-blockers are especially useful in patients with IHD or heart failure. Try to use cardioselective agents to minimise the risk of side effects. Do not combine with Verapamil or Diltiazem.

• Long-acting calcium channel blockers (if not previously used)

• Doxazosin must be used as 3rd or 4th line in hypertension when other agents have failed to lower the blood pressure. Doxazosin MR's Bioavailability compared to standard tabs 54% for 4mg and 58% for 8mg- i.e. little more than half. Doxazosin has an elimination half-life of 22 hours; there is no need for MR preparation to be prescribed unless there is a clear clinical benefit to the patient.