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The Pressure Is On
Hypertension and Diabetes

by Craig G. Hurwitz, MD

Just as sleep disorders are known to increase blood pressure, good sleep habits benefit blood pressure. In people without hypertension, blood pressure has been found to be higher in the morning after a poor night’s sleep. Psychological stress plays a role in hypertension, and stress-reduction and relaxation techniques are beneficial and important parts of a complete treatment program.

Drug therapy
In people with diabetes diagnosed with high blood pressure, drug therapy is initiated along with lifestyle changes. Many advances have been made in the understanding of what causes hypertension. This has resulted in the development of a number of different types, or classes, of drugs that lower blood pressure. The major classes of blood-pressure-lowering drugs include diuretics (often called water pills), angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), beta-blockers, alpha-blockers, and calcium channel blockers.

All of these classes are commonly used to treat high blood pressure in people with diabetes, but ACE inhibitors and ARBs should be considered as first-line treatment. Over the past few decades, numerous studies have shown that these medicines have protective effects independent of their ability to lower blood pressure: They also reduce the complications of diabetes including heart disease, stroke, and kidney disease. Further studies are looking into whether using both ACE inhibitors and ARBs together would provide even better cardiovascular and kidney protection. These medicines have become the cornerstone of blood pressure treatment, and there is even some evidence that they may prevent or delay the onset of diabetes.

Calcium channel blockers (CCBs) work by relaxing blood vessels, leading to lower blood pressure. They come in two forms, dihydropyridine (DHP) and non-dihydropyridine (non-DHP) CCBs. The non-DHP CCBs have some protective effects on the kidney not seen with DHP CCBs. The use of non-DHP CCBs in combination with ACE inhibitor and ARB therapy to amplify kidney and heart protection is an area of ongoing research.

Diuretics continue to be a very important class of blood pressure medicines. They reduce a person’s salt and water content by stimulating urination. They work best when a person is following a salt-restricted diet. Beta-blockers lower the blood pressure and slow the heart rate. They have been found to have significant heart-protective qualities, reducing the risk of death after a heart attack and improving the treatment of heart failure. However, both diuretics and beta-blockers are less desirable as first-line treatments in people with diabetes. These medicines may have negative effects on blood glucose control and weight. However, they are often needed eventually if the blood pressure is difficult to control.

Numerous other blood pressure medicines are available and work in many different ways. As a person is treated for high blood pressure, his medicines are gradually increased and “stacked” one on top of another until the goal blood pressure is achieved. On average, it generally takes three or more blood pressure medicines to adequately control high blood pressure in people with diabetes. While some medicines are more beneficial for people with diabetes than others, reaching the target blood pressure of below 140/80 mm Hg without side effects is the goal. If a person is unable to tolerate therapy with ACE inhibitors or ARBs, this goal must be achieved using other medicines. The cost of many of these medicines is high, and for some people cost may play a role in the choice of drugs as well.

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