Diabetes and Hypertension:A Position Statement by theAmerican Diabetes AssociationDiabetes Care 2017;40:1273–1284 | https://doi.org/10.2337/dci17-0026

Hypertension is common among patients with diabetes, with the prevalence depend-ing on type and duration of diabetes, age, sex, race/ethnicity, BMI, history of glycemiccontrol, and the presence of kidney disease, among other factors (1–3). Furthermore,hypertension is a strong risk factor for atherosclerotic cardiovascular disease (ASCVD),heart failure, andmicrovascular complications. ASCVDddefined as acute coronarysyndrome, myocardial infarction (MI), angina, coronary or other arterial revasculariza-tion, stroke, transient ischemic attack, or peripheral arterial disease presumed to be ofatherosclerotic origindis the leading cause of morbidity and mortality for individualswith diabetes and is the largest contributor to the direct and indirect costs of diabetes.Numerous studies have shown that antihypertensive therapy reduces ASCVD events,heart failure, and microvascular complications in people with diabetes (4–8). Largebenefits are seen when multiple risk factors are addressed simultaneously (9). There isevidence that ASCVDmorbidity andmortality have decreased for people with diabetessince 1990 (10,11) likely due in large part to improvements in blood pressure control(12–14). This Position Statement is intended to update the assessment and treatmentof hypertension amongpeoplewith diabetes, including advances in care since theAmericanDiabetes Association (ADA) last published a Position Statement on this topic in 2003 (3).

DEFINITIONS, SCREENING, AND DIAGNOSIS

Recommendations

c Blood pressure should be measured at every routine clinical care visit. Patientsfound to have an elevated blood pressure ($140/90 mmHg) should have bloodpressure confirmed using multiple readings, including measurements on a sep-arate day, to diagnose hypertension. B

c All hypertensive patients with diabetes should have home blood pressure mon-itored to identify white-coat hypertension. B

c Orthostatic measurement of blood pressure should be performed during initialevaluation of hypertension and periodically at follow-up, or when symptoms oforthostatic hypotension are present, and regularly if orthostatic hypotension hasbeen diagnosed. E

Blood pressure should be measured at every routine clinical care visit (15). At the ini-tial visit, blood pressure should be measured in both arms to detect and account forabnormalities that may lead to spurious blood pressures, such as arterial stenosis.Patients with elevated blood pressure ($140/90 mmHg) who are not known to havehypertension should have elevated blood pressure confirmedon a separate day,within1 month, to confirm the diagnosis of hypertension.Office-based semiautomated oscillometric blood pressure (conventional or office

blood pressure) is the conventional method used to diagnose hypertension and mon-itor treatment response. Blood pressure should be measured by a trained individual(15) in the seated position, with feet on the floor and arm supported at heart level. Cuffsize should be appropriate for the upper-arm circumference (Table 1). To reducewithin-patient variability, blood pressure should bemeasured after 5min of rest, 2–3 readingsshould be taken 1–2min apart, and blood pressure measurements should be averaged(16). It is particularly important tomake and average repeatedmeasurements of bloodpressure for the diagnosis of hypertension and titration of antihypertensive treatment.

1University of Washington, Seattle, WA2New York University, New York, NY3Universite de Lorraine, Nancy, France4The University of Chicago Medicine, Chicago, IL5The Johns Hopkins University School of Medi-cine, Baltimore, MD6School of Public Health, University of Alabamaat Birmingham, Birmingham, AL7Steno Diabetes Center Copenhagen, Universityof Copenhagen, Copenhagen, Denmark8School of Public Health and Preventive Medi-cine, Monash University, Melbourne, Australia

Corresponding author: George Bakris, gbakris@medicine.bsd.uchicago.edu.

This position statement was reviewed and ap-proved by the American Diabetes AssociationProfessional Practice Committee in June 2017and ratified by the American Diabetes Associa-tion Board of Directors in July 2017.

For further information on the ADA evidencegrading systemand the levels of evidence, pleasesee Table 1 in the American Diabetes Associa-tion’s Introduction section of the Standards ofMedical Care in Diabetesd2017. Diabetes Care2017;40(Suppl. 1):S2, https://doi.org/10.2337/dc17-S001.

This article is featured in a podcast available athttp://www.diabetesjournals.org/content/diabetes-core-update-podcasts.

© 2017 by the American Diabetes Association.Readers may use this article as long as the workis properly cited, the use is educational and notfor profit, and the work is not altered. More infor-mation is available at http://www.diabetesjournals.org/content/license.

Ian H. de Boer,1 Sripal Bangalore,2

Athanase Benetos,3 Andrew M. Davis,4

Erin D. Michos,5 Paul Muntner,6

Peter Rossing,7 Sophia Zoungas,8 and

George Bakris4

Diabetes Care Volume 40, September 2017 1273

POSITIO

NSTA

TEMEN

T

Automated office blood pressure (AOBP)is an alternate method to measure bloodpressure in which a fully automated deviceis used tomake and averagemultiple read-ings (usually 3–5) taken over a few min-utes, ideally while a patient rests quietlyalone (17). AOBP was used in two large,important clinical trials, Action to ControlCardiovascular Risk in Diabetes (ACCORD)(18) and Systolic Blood Pressure Interven-tion Trial (SPRINT) (19). If the patient isalone when the readings are taken, theapproach is also useful for diagnosingwhite-coat hypertension (20). AOBP gener-ates values 5–10 mmHg lower than con-ventional office readings, on average.Thus, results of trials using this techniquecannot be directly applied to practicesthat measure conventional office bloodpressure (17,21–23). With the exceptionof ACCORD (18), most of the evidence ofbenefits of hypertension treatment inpeople with diabetes is based on conven-tional office measurements.Hypertension is defined as a sustained

blood pressure $140/90 mmHg. Thisdefinition is based on unambiguous datathat levels above this threshold arestrongly associated with ASCVD, death,disability, andmicrovascular complications(1,2,24–27) and that antihypertensivetreatment in populations with baselineblood pressure above this range reducesthe risk of ASCVD events (4–6,28,29). The“sustained” aspect of the hypertensiondefinition is important, as blood pressurehas considerable normal variation. The cri-teria for diagnosing hypertension shouldbe differentiated from blood pressuretreatment targets.Hypertension diagnosis and manage-

ment can be complicated by two com-mon conditions: masked hypertensionandwhite-coat hypertension.Masked hy-pertension is defined as a normal bloodpressure in the clinic or office (,140/90mmHg) but an elevated homeblood pres-sure of $135/85 mmHg (30); the lowerhome blood pressure threshold is based

on outcome studies (31) demonstratingthat lower home blood pressures corre-spond to higher office-based measure-ments. White-coat hypertension is elevatedoffice blood pressure ($140/90 mmHg)and normal (untreated) homeblood pres-sure (,135/85 mmHg) (32). Identifyingthese conditions with home blood pres-sure monitoring can help prevent over-treatment of people with white-coathypertension who are not at elevatedrisk of ASCVD and, in the case of maskedhypertension, allow proper use of med-ications to reduce side effects during pe-riods of normal pressure (33,34).

Home blood pressure measurementsinclude daytime blood pressure mea-sured with ambulatory blood pressuremonitoring as well as measurementstaken with home blood pressure moni-tors. The cuff size is very important, astoo small a cuff will give higher than ac-tual blood pressure values and too large acuff will give values that are lower thanactual blood pressure. The correct cuffsize, such that the bladder encircles 80%of the arm (Table 1), should be used. Thecuff should be placed such that the mid-dle is on the patient’s upper arm at thelevel of the right atrium (the midpoint ofthe sternum), and it should never beplaced over clothes.

Orthostatic HypotensionDiabetic autonomic neuropathy or vol-ume depletion can cause orthostatic hy-potension (35), which may be furtherexacerbated by antihypertensive medica-tions. The definition of orthostatic hypo-tension is a decrease in systolic bloodpressure of 20 mmHg or a decrease indiastolic blood pressure of 10 mmHgwithin 3 min of standing when comparedwith blood pressure from the sitting orsupine position (36). Orthostatic hypo-tension is common in people with type 2diabetes and hypertension and is associ-ated with an increased risk of mortalityand heart failure (37).

It is important to assess for symptomsof orthostatic hypotension to individual-ize blood pressure goals, select the mostappropriate antihypertensive agents, andminimize adverse effects of antihyper-tensive therapy. Additionally, antihyper-tensive medication type or timing (switchto nocturnal dosing) may require adjust-ment. In particular, a-blockers and di-uretics may need to be stopped. Peoplewith orthostatic hypotensionmay benefit

fromsupport stockingsorotherapproaches(38).

BLOOD PRESSURE TARGETS

Recommendations

c Most patientswith diabetes andhy-pertension should be treated to asystolic blood pressure goal of,140mmHg and a diastolic blood pres-sure goal of,90 mmHg. A

c Lower systolic and diastolic bloodpressure targets, such as ,130/80mmHg, may be appropriate for in-dividuals at high risk of cardiovascu-lar disease if they can be achievedwithout undue treatment burden.B

Epidemiologic analyses show that bloodpressure $115/75 mmHg is associatedwith increased rates of ASCVD (27), heartfailure, retinopathy, kidney disease, andmortality in a graded fashion, contribut-ing to the evidence that blood pressurecontrol is important in the clinical outcomesof diabetes (1,2,24,26,39). However, ob-servational studies of blood pressure tar-gets are subject to confounding factorsand do not directly assess the effects ofblood pressure lowering. Clinical trials andmeta-analyses of clinical trials provide thestrongest evidence addressing blood pres-sure and offer substantial guidance fortreatment targets, particularly for patientswith type 2 diabetes.

Treatment of hypertension to bloodpressure ,140/90 mmHg is supported byunequivocal evidence that pharmacologictreatment of blood pressure $140/90mmHg reduces cardiovascular events aswell as some microvascular complica-tions. In type 2 diabetes, the UK Prospec-tive Diabetes Study (UKPDS) showed thattargeting blood pressure,150/85mmHgversus ,180/105 mmHg reduced com-posite microvascular and macrovasculardiabetes complications by 24% (28).Moreover, meta-analyses of clinical trialsdemonstrate that antihypertensive treat-ment of populations with diabetes andbaseline blood pressure $140/90 mmHgreduces the risks of ASCVD, heart failure,retinopathy, and albuminuria (4–8,40).Therefore, most patients with type 1 ortype 2 diabetes who have hypertensionshould, at aminimum, be treated tobloodpressure targets of,140/90 mmHg.

Intensification of antihypertensivetherapy to target blood pressures lowerthan ,140/90 mmHg (e.g., ,130/80

Table 1—Recommended blood pressuremeasurement cuff size for a given armcircumference

Arm circumference (cm) Usual cuff size

22–26 Small adult

27–34 Adult

35–44 Large adult

45–52 Adult thigh

1274 Position Statement Diabetes Care Volume 40, September 2017

or,120/80 mmHg)may be beneficial forselected patients with diabetes. Such in-tensive blood pressure control has beenevaluated in landmark clinical trials andmeta-analyses of clinical trials.

Randomized Clinical Trials of IntensiveBlood Pressure ControlThe ACCORD blood pressure (ACCORDBP) trial examined the effects of intensiveblood pressure control (goal systolicblood pressure,120mmHg) versus stan-dard blood pressure control (target sys-tolic blood pressure,140mmHg) amongpeople with type 2 diabetes. Additionalstudies, such as Hypertension OptimalTreatment (HOT) trial and SPRINT, alsoexamined the potential benefits of in-tensive versus standard blood pressure

control, though the relevance of their re-sults to people with diabetes is less clear.The Action in Diabetes and VascularDisease: Preterax and Diamicron MRControlled Evaluation–Blood Pressure(ADVANCE BP) trial, which tested theeffects of a fixed-dose combination ofantihypertensive interventions versusplacebo among people with type 2 diabe-tes, also informs blood pressure targets(41). Study details are given in Table 2.

In ACCORD BP, intensive blood pres-sure control did not reduce total majoratherosclerotic cardiovascular eventsbut did reduce the risk of stroke, at theexpense of increased adverse events (18).Specifically, compared with a target sys-tolic blood pressure ,140 mmHg, a tar-get systolic blood pressure ,120 mmHg

resulted in no significant difference inthe primary composite outcome of MI,stroke, or cardiovascular death (hazardratio 0.88, 95% CI 0.73 to 1.06). Strokewas reduced by 41% (hazard ratio 0.59,95% CI 0.39 to 0.89), but serious adverseevents attributed to antihypertensivetherapy occurred in 3.3% vs. 1.3% ofparticipants, with significantly increasedincidence of hypotension, electrolyte ab-normalities, and elevated serum creati-nine. Therefore, the ACCORD BP resultssuggest that blood pressure targets moreintensive than ,140/90 mmHg may bereasonable in selected patients who havebeen educated about added treatmentburden, side effects, and costs (18,42).The achieved blood pressure in ADVANCEin the intervention group (136/73) was

Table 2—Randomized controlled trials of intensive vs. standard hypertension treatment strategies

Clinical trial Population Intensive Standard Outcomes

ACCORD BP (18) 4,733 participants with T2Daged 40–79 years withprior evidence of CVD ormultiple cardiovascularrisk factors

Systolic blood pressuretarget: ,120 mmHg

Achieved (mean) systolic/diastolic: 119.3/64.4mmHg

Systolic blood pressuretarget: 130–140 mmHg

Achieved (mean) systolic/diastolic: 133.5/70.5mmHg

c No benefit in primary end point:composite of nonfatal MI,nonfatal stroke, and CVD death

c Stroke risk reduced 41% withintensive control, not sustainedthrough follow-up beyond theperiod of active treatment

c Adverse events more common inintensive group, particularlyelevated serum creatinine andelectrolyte abnormalities

ADVANCE BP (43) 11,140 participants withT2D aged 55 years andolder with prior evidenceof CVD or multiplecardiovascular riskfactors

Intervention: a single-pill,fixed-dose combinationof perindopril andindapamide

Achieved (mean) systolic/diastolic: 136/73mmHg

Control: placeboAchieved (mean) systolic/diastolic: 141.6/75.2mmHg

c Intervention reduced risk ofprimary composite end point ofmajor macrovascular andmicrovascular events (9%), deathfrom any cause (14%), and deathfrom CVD (18%)

c 6-year observational follow-upfound reduction in risk of death inintervention group attenuated butstill significant (134)

HOT (135) 18,790 participants,including 1,501 withdiabetes

Diastolic blood pressuretarget: #80 mmHg

Diastolic blood pressuretarget: #90 mmHg

c In the overall trial, there was nocardiovascular benefit with moreintensive targets

c In the subpopulation withdiabetes, an intensive diastolictarget was associated with asignificantly reduced risk (51%) ofCVD events

SPRINT (19) 9,361 participants withoutdiabetes

Systolic blood pressuretarget: ,120 mmHg

Achieved (mean): 121.4mmHg

Systolic blood pressuretarget: ,140 mmHg

Achieved (mean): 136.2mmHg

c Intensive systolic blood pressuretarget lowered risk of the primarycomposite outcome 25% (MI,acute coronary syndrome, stroke,heart failure, and death due toCVD)

c Intensive target reduced risk ofdeath 27%

c Intensive therapy increased risksof electrolyte abnormalities andacute kidney injury

CVD, cardiovascular disease; T2D, type 2 diabetes.

care.diabetesjournals.org de Boer and Associates 1275

higher than that achieved in ACCORDintensive arm (119/64 mmHg) andwould be consistent with a targetbloodpressureof,140/90mmHg, thoughADVANCE did not explicitly test bloodpressure targets (43). Of note, ACCORDBP and SPRINT measured blood pres-sure using AOBP, which yields valuesthat are generally lower than typical of-fice blood pressure by approximately5–10 mmHg (17), suggesting that imple-menting the ACCORD BP or SPRINT pro-tocols in a typical clinic might require asystolic blood pressure target higherthan ,120 mmHg.

Meta-analyses of TrialsMeta-analyses of placebo-controlledclinical trials using multiple classes of an-tihypertensive medications clearly dem-onstrate that antihypertensive treatmentin general reduces the risks of ASCVD,heart failure, retinopathy, albuminuria,and mortality among people with diabe-tes (4–8,40). Overall, compared with peo-plewithout diabetes, the relative benefitsof antihypertensive treatment are similar,and absolute benefits may be greater(5,8,40). To clarify optimal blood pressuretargets in the setting of diabetes, meta-analyses have stratified clinical trials bymean baseline blood pressure or meanblood pressure attained in the interven-tion or intensive treatment arm. Basedon these analyses, antihypertensive treat-ment appears to be beneficial when meanbaselinebloodpressure is$140/90mmHgor mean attained intensive blood pres-sure is $130/80 mmHg (4,6–8). Amongtrials with lower baseline or achievedblood pressure, antihypertensive treat-ment reduced the risk of stroke, retinop-athy, and albuminuria, but effects onother ASCVD and heart failure were notevident. A critical point is that these areall trial-level meta-analyses that are sub-ject to confounding and imprecise in theirstratification, as opposed to individual-level meta-analyses, which are neededto best address the issue (8). In addition,meta-analyses have focused largely ontreatment benefits, and additional dataweighing potential harms are needed.Taken together, these meta-analysesconsistently show that treating patientswith baseline blood pressure $140mmHg to targets ,140 mmHg is benefi-cial, while more intensive targets may of-fer additional thoughprobably less robustbenefits.

Individualization of Treatment TargetsPatients and clinicians should engage in ashared decision-making process to deter-mine individual blood pressure targets,with the acknowledgment that the bene-fits and risks of intensive blood pressuretargets are uncertain andmay vary acrosspatients. Following the ADA approachto the management of hyperglycemia,factors that influence treatment targetsmay include risks of treatment (e.g., hy-potension, drug adverse effects), lifeexpectancy, comorbidities includingvascular complications, patient atti-tude and expected treatment efforts,and resources and support system(44). Specific factors to consider are theabsolute risk of cardiovascular events(40,45), risk of progressive kidney diseaseas reflected by albuminuria, adverse ef-fects, age, and overall treatment burden.Patients who have higher risk of cardio-vascular events (particularly stroke) or al-buminuria and who can attain intensiveblood pressure control relatively easilyand without substantial adverse effectsmay be best suited to intensive bloodpressure control. In contrast, patientswith conditions more common in olderadults, such as functional limitations, pol-ypharmacy, and multimorbidity, may bebest suited to less intensive blood pres-sure control.

Notably, there is an absence of high-quality data available to guide bloodpressure targets in type 1 diabetes. Asso-ciations of blood pressure withmacrovas-cular and microvascular outcomes intype 1 diabetes are generally similar tothose in type 2 diabetes and the generalpopulation (1). Given an absence of ran-domized trials with clinical outcomes intype 1 diabetes, effects of antihyperten-sive therapy can only be extrapolatedfrom trials in other populations, poten-tially drawing from both ACCORD BPand SPRINT. Of note, diastolic bloodpressure, as opposed to systolic bloodpressure, is a key variable predicting car-diovascular outcomes in people underage 50 years without diabetes and maybe prioritized in younger adults (46,47).Though convincing data are lacking, youn-ger adults with type 1 diabetes mightmore easily achieve intensive blood pres-sure levels and may derive substantiallong-term benefit from tight blood pres-sure control.

TREATMENT

Lifestyle Management

Recommendation

c For patients with systolic bloodpressure .120 mmHg or diastolicblood pressure .80 mmHg, life-style intervention consists ofweightloss if overweight or obese; a DietaryApproaches to Stop Hypertension(DASH)-style dietary pattern includ-ing reduced sodium and increasedpotassium intake; increased fruitand vegetable consumption;moder-ationof alcohol intake; and increasedphysical activity. B

Lifestyle management is an importantcomponent of hypertension treatmentbecause it lowers blood pressure, en-hances the effectiveness of some antihy-pertensive medications, promotes otheraspects of metabolic and vascular health,and generally leads to few adverse ef-fects. In addition, patients with diabetesand systolic blood pressure.120 mmHgor diastolic blood pressure .80 mmHgare at risk for developing hypertensionand its complications (48,49), and lifestylemanagementmay help prevent or delay adiagnosis of hypertension with need forpharmacologic therapy. To facilitate long-term maintenance of behavioral change,lifestyle therapy should beadapted to suitthe needs of the patient and discussed aspart of diabetes management.

Although there are no well-controlledstudies of diet and exercise in the treat-ment of elevated blood pressure or hy-pertension in individuals with diabetes,theDietary Approaches to StopHyperten-sion (DASH) study evaluated the impactof healthy dietary patterns in individualswithout diabetes and has shown antihy-pertensive effects similar to those ofpharmacologic monotherapy (50). A re-cent meta-analysis found that lifestyle in-tervention can help lower blood pressurein patients with type 2 diabetes (51).Medium- or high-intensity combined life-style counseling has shown benefit in pa-tients selected for cardiovascular riskfactors, including diabetes, for the inter-mediate outcomes of blood pressure, lip-ids, fasting blood glucose, and weight,especially over 12 to 24 months (52).

Lifestyle therapy consists of reducingexcess bodyweight through caloric restric-tion, restricting sodium intake (,2,300mg/day), increasing consumption of fruits

1276 Position Statement Diabetes Care Volume 40, September 2017

and vegetables (8–10 servings per day)and low-fat dairy products (2–3 servingsper day), avoiding excessive alcohol con-sumption (no more than 2 servings perday in men and no more than 1 servingper day in women) (53), smoking cessa-tion, reducing sedentary time (54), andincreasing physical activity levels (55).These lifestyle strategies may also posi-tively affect glycemic and lipid controland should be encouraged in those witheven mildly elevated blood pressure. Inaddition, clinicians are encouraged toroutinely review patient medication listsfor agents that may raise blood pres-sure, including over-the-counter andherbal ones. As an example, one meta-analysis suggested that nonsteroidalanti-inflammatory drugs increase systolicblood pressure on average by 5 mmHg(56).

Sodium

Sodium reduction has not been tested incontrolled clinical trials in people withdiabetes. However, results from trials inprimary hypertension have shown a reduc-tion in systolic blood pressure of ;5mmHg and diastolic blood pressure of2–3 mmHg with moderate sodium reduc-tion (from a daily intake of 200 mmol[4,600 mg] to 100 mmol [2,300 mg] ofsodium per day) (57). A dose-response ef-fect has been observedwith sodium reduc-tion. Even when pharmacologic agents areused, theremaybeabetter responsewhenthere is concomitant salt restriction due tothe volume component of hypertension.

Physical Activity

Moderately intense physical activity, suchas 30–45 min of brisk walking most daysof theweek, hasbeenshownto lowerbloodpressure (58). Regular exercise may lowerblood pressure, necessitating dose adjust-ment of antihypertension medications(59). b-Blockers may reduce maximalexercise capacity, while diuretics may in-crease risk of dehydration. Physical activ-ities should be promoted in all patientsincluding older adults with physical limi-tations. The type and intensity of physicalactivities should be adapted to the prefer-ences and functional status of the patient.

Weight Loss

Weight reduction should be consideredin the management of blood pressure.The loss of 1 kg in body weight has beenassociated with a decrease in blood pres-sure of;1 mmHg (60). Some weight-lossmedications may induce increases in

blood pressure levels, so these must beused with care.

Sleep Apnea

Treatment of obstructive sleep apneahas been shown to reduce blood pres-sure in randomized studies of peoplewith diabetes (61).

Pharmacologic AntihypertensiveTreatment

Recommendations

c Patients with confirmed office-based blood pressure $140/90mmHg should, in addition to life-style therapy, have timely titrationof pharmacologic therapy to achieveblood pressure goals. A

c Patients with confirmed office-based blood pressure $160/100mmHg should, in addition to life-style therapy, have prompt initia-tion and timely titration of twodrugs or a single-pill combinationof drugs demonstrated to reducecardiovascular events in patientswith diabetes. A

c Treatment for hypertension shouldinclude drug classes demonstratedto reduce cardiovascular events inpatients with diabetes: ACE inhibi-tors, angiotensin receptor blockers(ARBs), thiazide-like diuretics, ordihydropyridine calcium channelblockers. Multiple-drug therapy isgenerally required to achieve bloodpressure targets (but not a combina-tion of ACE inhibitors and ARBs). A

c AnACE inhibitor or ARB, at themax-imum tolerated dose indicated forblood pressure treatment, is therecommended first-line treatmentfor hypertension in patients withdiabetes and urine albumin-to-creatinine ratio $300 mg/g creati-nine (A) or 30–299 mg/g creatinine(B). If one class is not tolerated, theother should be substituted. B

c For patients treated with an ACEinhibitor, ARB, or diuretic, serumcreatinine/estimated glomerularfiltration rate and serum potassiumlevels should be monitored. B

Initial Number of Antihypertensive

Medications

Initial treatment for people with diabetesdepends on the severity of hypertension(Fig. 1). Those with blood pressure be-tween 140/90 mmHg and 159/99 mmHg

may begin with a single drug. For patientswith blood pressure $160/100 mmHg,initial pharmacologic treatment withtwo antihypertensive medications is rec-ommended. The Study of Hypertensionand the Efficacy of Lotrel in Diabetes(SHIELD) trial was one of the first trialsto evaluate whether a higher percentageof people with diabetes would achievethe blood pressure goal when a single-pill combination was given rather thanmonotherapy at average blood pressuresabove 160/100 mmHg. The 214 patientsreceived initial therapywith an ACE inhib-itor plus dihydropyridine calcium channelblocker (CCB) compared with the ACEinhibitor alone, which resulted in an in-creasedproportionof participants achiev-ing the target blood pressure at 3 months(63% vs. 37%; P 5 0.002) (62). The Sim-plified Treatment Intervention to ControlHypertension (STITCH) trial randomizedover 2,000 patients with and without di-abetes whose mean blood pressure was;160/95mmHg to anACE inhibitor aloneor ACE inhibitor plus thiazide-like diureticand found that the proportion of patientsachieving a blood pressure ,140/90mmHg at 6 months was higher in the com-bination intervention group (65% vs. 53%;P 5 0.026) (63). Single-pill combinationsmay improve medication adherence (64).

Classes of Antihypertensive Medications

Initial treatment for hypertension shouldinclude drug classes demonstrated to re-duce cardiovascular events in patientswith diabetes: ACE inhibitors (65,66), an-giotensin receptor blockers (ARBs) (65,66),thiazide-like diuretics (67), or dihydropyr-idine CCBs (68). For patients with albu-minuria (urine albumin-to-creatinineratio [UACR]$30mg/g creatinine), initialtreatment should include anACE inhibitoror ARB in order to reduce the risk of pro-gressive kidney disease, detailed below. Inthe absence of albuminuria, risk of progres-sive kidneydisease is low, andACE inhibitorsand ARBs have not been found to affordsuperior cardioprotection when comparedwith other antihypertensive agents (69).b-Blockersmaybe used for the treatmentof coronary disease or heart failure buthave not been shown to reduce mortalityas blood pressure–lowering agents in theabsence of these conditions (5,70).

Multiple-Drug Therapy

Multiple-drug therapy is often required toachieve blood pressure targets, particularlyin the setting of diabetic kidney disease.

care.diabetesjournals.org de Boer and Associates 1277

However, the use of both ACE inhibitorsand ARBs in combination is not recom-mended given the lack of added ASCVDbenefit and increased rate of adverseeventsdnamely, hyperkalemia, syncope,and acute kidney injury (71–73). Titrationof and/or addition of further blood

pressure medications should be madein a timely fashion to overcome clinical in-ertia in achieving blood pressure targets.

There is only one large trial includingpeople with diabetes that randomizedtwo single-pill combinations and assessedcardiovascular and renal outcomes. The

Avoiding Cardiovascular Events ThroughCombination Therapy in Patients LivingWith Systolic Hypertension (ACCOMPLISH)trial enrolled participants at high risk of car-diovascular events (60%with diabetes) anddemonstrated a decrease in morbidity andmortality with the ACE inhibitor benazepril

Figure 1—Recommendations for the treatment of confirmed hypertension in people with diabetes. *An ACE inhibitor (ACEi) or ARB is suggested totreat hypertension for patientswithUACR 30–299mg/g creatinine and strongly recommended for patientswithUACR$300mg/g creatinine. **Thiazide-like diuretic; long-acting agents shown to reduce cardiovascular events, such as chlorthalidone and indapamide, are preferred. ***Dihydropyridine. BP,blood pressure.

1278 Position Statement Diabetes Care Volume 40, September 2017

plus the dihydropyridine CCB amlodipineversus benazepril and the thiazide-like di-uretic hydrochlorothiazide (68,74). Othersuch trials are needed to confirm theseoutcomes and assess other antihyperten-sive medication combinations.

Diabetic Kidney Disease

Patients with diabetes and albuminuria(UACR $30 mg/g creatinine and parti-cularly $300 mg/g creatinine) are at in-creased risk of progressive kidney disease(24). In this setting, ACE inhibitors andARBs have unique renoprotective advan-tages in the treatment of hypertension.Outcome trials of people with type 1and type 2 diabetes and established di-abetic kidney disease (including urinaryalbumin excretion$300mg/g creatinine)have demonstrated that an ACE inhibitoror ARB, at a maximal antihypertensivedose, slows the progression of kidney dis-ease compared with placebo (75–77).Therefore, patients with urinary albuminexcretion $300 mg/g creatinine shouldhave an ACE inhibitor or an ARB includedas part of their blood pressure–loweringregimen. Clinicians should also consideran ACE inhibitor or ARB in patients withhypertension at any level of albuminuria(urinary albumin excretion $30 mg/gcreatinine) (66).In the absence of albuminuria, the su-

periority of ACE inhibitors or ARBs overother antihypertensive agents for preven-tion of cardiovascular outcomes has notbeen consistently shown (66,69,78,79),although smaller trials suggest reductionin composite cardiovascular events andreduced progression to advanced stagesof kidney disease (80–82). In general, ACEinhibitors and ARBs are considered tohave similar benefits and risks, and if oneis not tolerated, the other can oftenbe used (65,83).

Hyperkalemia and Acute Kidney Injury

In people with diabetic kidney disease,hyperkalemia risk dramatically increaseswhen the estimated glomerular filtrationrate (eGFR) is below 45 mL/min/1.73 m2

or serum potassium is.4.5 mEq/L whilethe patient is already receiving a diuretic(84).Moreover, thecombinationof reducedeGFR and elevated potassium in a given pa-tient can raise the risk eightfold for hyper-kalemia development if spironolactone andan ACE inhibitor or ARB are added (85).Thiazide-like diuretics are only effec-

tive in maintaining volume and reducingthe risk of hyperkalemia down to an eGFR

of 30 mL/min/1.73 m2 (86,87). Below aneGFRof 30mL/min/1.73m2, a long-actingloop diuretic, such as torsemide, shouldbe prescribed instead.

To prevent inadvertent declines ineGFR, patients treated with an ACE inhib-itor or ARB should be aware of volumestatus and avoid volume depletion to re-duce the risk for acute kidney injury. Also,in volume depleted states, risk for hyper-kalemia increases (71,72,88).

Bedtime Dosing

Evidence suggests an association betweenabsence of nocturnal blood pressure dip-ping and ASCVD events. A meta-analysisof clinical trials found a small benefit ofevening versus morning dosing of anti-hypertensive medications with regard toblood pressure control but no data onclinical effects (89). In two subgroupanal-yses of a single subsequent randomizedclinical trial, moving at least one antihy-pertensive medication to bedtime signif-icantly reduced cardiovascular events,but results were based on small numbersof events (90,91).

Monitoring

Recommendation

c In patients receiving pharmacologicantihypertensive treatment, homeblood pressure should bemeasuredto promote patient engagement intreatment and adherence. B

Self-management is a key component ofdiabetes care and extends to antihyper-tensive treatment. Home blood pressuresmay improve patient medication adher-ence (92–94) and reduce cardiovascularrisk factors (95). Furthermore, evidencesuggests home blood pressure monitor-ing is as accurate as 24-h ambulatoryblood pressure monitoring (96,97) andmay better correlate with ASCVD riskthan office measurements (98,99).

Interactions with Diabetes MedicationsHyperinsulinemia and exogenous insulinmay theoretically lead to hypertensionthrough vasoconstriction and sodiumand fluid retention (100). However, insu-lin can also promote vasodilation, and basalinsulin compared with standard care wasnot associated with a change in blood pres-sure in the Outcome Reduction With anInitial Glargine Intervention (ORIGIN) trialof people with type 2 diabetes or prediabe-tes (101).

Sodium–glucose cotransport 2 inhibi-tors are associated with a mild diureticeffect and a reduction in blood pressureof 3–6 mmHg systolic blood pressure and1–2 mmHg diastolic blood pressure(102,103). Glucagon-like peptide 1 recep-tor agonists are also associated with areduction in systolic/diastolic blood pres-sure of 2–3/0–1 mmHg (104).

RESISTANT HYPERTENSION

Recommendations

c Patients with resistant hypertensionwho are notmeeting blood pressuretargets on conventional drug ther-apy with three agents, including adiuretic, should be referred to a cer-tified hypertension specialist. E

c Patients with resistant hypertensionwho arenotmeeting bloodpressuretargets on conventional drug ther-apy with three agents should beconsidered formineralocorticoid re-ceptor antagonist therapy. B

Resistant hypertension is defined asblood pressure $140/90 mmHg despitea therapeutic strategy that includes ap-propriate lifestyle management plus a di-uretic and two other antihypertensivedrugs belonging to different classes atadequate doses. Prior to diagnosing resis-tant hypertension, several other condi-tions should be excluded (Table 3).

Since multiple agents are often neces-sary to achieve blood pressure targets,medication adherence issues may pre-sent as resistant hypertension. Potentialbarriers tomedication adherence (such ascost, number of medications, and sideeffects) should routinely be assessed. Ifblood pressure remains uncontrolled de-spite confirmed adherence, cliniciansshould consider an evaluation for second-ary causes of hypertension.

Mineralocorticoid receptor antagonists(MRAs) are effective for management ofresistant hypertension in patients withtype 2 diabetes when added to existingtreatmentwith a renin-angiotensin system(RAS) inhibitor, diuretic, and CCB (105), inpart because they reduce sympatheticnerve activity (106). MRAs also reducealbuminuria and have additional cardio-vascular benefits (107–110). However,adding an MRA to an ACE inhibitor orARB may increase the risk for hyper-kalemic episodes. Hyperkalemia canbe managed with dietary potassium

care.diabetesjournals.org de Boer and Associates 1279

restriction, potassium-wasting diuretics,or potassium binders (111), but long-termoutcome studies are needed to eval-uate the role of MRAs (with or withoutadjunct potassiummanagement) in bloodpressure management.

PREGNANCY

Recommendations

c Pregnant womenwith diabetes andpreexisting hypertension or mild ges-tational hypertension with systolicblood pressure ,160 mmHg, dia-stolic blood pressure ,105 mmHg,and no evidence of end-organ dam-age do not need to be treated withpharmacologic antihypertensivetherapy. E

c In pregnant patients with diabetesand preexisting hypertension whoare treated with antihypertensivetherapy, systolic or diastolic bloodpressure targets of 120–160/80–105 mmHg are suggested in theinterest of optimizing long-termmaternal health and fetal growth. E

The American College of Obstetriciansand Gynecologists (ACOG) does notrecommend that womenwithmild gesta-tional hypertension (systolic blood pres-sure ,160 mmHg or diastolic bloodpressure ,110 mmHg) be treated withantihypertensive medications, as thereis no benefit identified that clearly out-weighs potential risks of therapy (112).A Cochrane systematic review did notfind conclusive evidence for or againstblood pressure treatment for mild tomoderate preexisting hypertension toreduce the risk of preeclampsia, pretermbirth, small-for-gestational-age infants, orfetal death (113). For pregnant women athigh risk of preeclampsia, low-dose aspi-rin is recommended starting at 12 weeksof gestation to reduce the risk ofpreeclampsia (114).

For women requiring antihypertensivetherapy, blood pressure should be main-tained between 120 and 160 mmHg sys-tolic and 80 and 105 mmHg diastolic, aslower blood pressure levels may be asso-ciated with impaired fetal growth. Preg-nant women with hypertension andevidence of end-organ damage includingcardiovascular and renal diseases may beconsidered for lower blood pressure tar-gets (i.e., ,140/90 mmHg) to avoid theprogression of these diseases duringpregnancy.

During pregnancy, treatment with ACEinhibitors, ARBs, or spironolactone is con-traindicated, as they may cause fetaldamage. Antihypertensive drugs knownto be effective and safe in pregnancy in-clude methyldopa, labetalol, hydralazine,and long-acting nifedipine. Diuretics maybe used during late-stage pregnancyif needed for volume control (115).Postpartum patients with gestational hy-pertension, preeclampsia, and superim-posed preeclampsia should have theirblood pressures observed for 72 h in thehospital and for 7–10 days’ postpartum(112). Long-term follow-up is recom-mended for these women, as they haveincreased lifetime cardiovascular risk.

OLDER ADULTS (AGED ‡65 YEARS)

Arterial stiffness may develop during theaging process and contribute to an in-crease in systolic and decrease in diastolicblood pressure in older adults (116,117).Diabetes is itself associated with an in-crease in arterial stiffness (118), leadingto a greater age-related increase in sys-tolic blood pressure compared with peo-ple without diabetes (119–121). Olderadults with diabetes and hypertension(mainly systolic) typically present withhigh risk for cardiovascular events andother age-related diseases (122–124), dif-ficulties achieving blood pressure targetsdue to arterial stiffness, and high risk of

iatrogenic complications, including hypo-glycemia, orthostatic hypotension, andvolume depletion.

In older adults with diabetes and hy-pertension, functional status, comorbid-ities, and polypharmacy are importantconsiderations when establishing ther-apeutic strategies and blood pressuregoals (125). Systolic blood pressureshould be the main target of treatment.In fitter patients, a therapeutic strategysimilar to that used in younger individualsmay be used. In the subgroupwith loss ofautonomy and major functional limita-tions (e.g., those needing daily assistancefor their basic activities), higher systolicblood pressure goals should be consid-ered (e.g., 145–160 mmHg) and treat-ment should be reduced in the presenceof low supine systolic blood pressure(,130 mmHg) or presence of orthostatichypotension (125,126).

In older people with impaired vascularcompliance, as indicated by a differenceof .60 mmHg between systolic and di-astolic pressures (i.e., pulse pressure), at-tempts to reach a target systolic pressuremust be balanced against the risk of low-ering diastolic pressure below 65–70mmHg. Lowering diastolic pressures be-low this range in older adultsmay increasethe risk for coronary heart disease, mor-tality, and other adverse cardiovascularoutcomes (127–130).

When considering pharmacologic anti-hypertensive treatment in older adultswith diabetes, note that b-blockers maymask signs of hypoglycemia, antihyper-tensive drugs can worsen orthostatic hy-potension, and diuretics can exacerbatevolume depletion. Cognitive dysfunctionmay affect medication-taking behaviors,particularly in the context of poor overallhealth status, multiple comorbidities,acute illness, polypharmacy, and poor nu-trition. Tolerance of the antihypertensivetreatment should be regularly assessed,especially orthostatic hypotension.

Table 3—Conditions to exclude before making the diagnosis of resistant hypertension

Conditions Definition

Secondary hypertension (136)* Hypertension elicited or exacerbated by other drugs or diseases

Pseudoresistance (136,137) Apparent hypertension due to lack of medication adherence, poor blood pressure measurementtechnique

Masked hypertension (137) Clinic blood pressure ,140/90 mmHg; daytime blood pressure$135 or$85 mmHg

White-coat hypertension (137) Clinic blood pressure $140 or$90 mmHg; daytime blood pressure,135/85 mmHg

*Secondary causes of hypertension include endocrine issues, renal arterial disease, excessive edema in advanced kidney disease, and hormones, such astestosterone. Drugs that increase blood pressure include NSAIDs, decongestants, and some illicit substances.

1280 Position Statement Diabetes Care Volume 40, September 2017

ANTIHYPERTENSIVE TREATMENTIN THE ABSENCE OFHYPERTENSION

For people with diabetes and untreatedblood pressure,140/90 mmHg, there islittle evidence that antihypertensivetreatment improves health outcomes.Some have suggested treatment with anACE inhibitor or ARB to prevent or delaydiabetic kidney disease, but the data donot support such an approach. In a trial ofpeople with type 2 diabetes and normalurine albumin excretion with andwithouthypertension, an ARB reduced or sup-pressed the development of albuminuriabut increased the rate of cardiovascularevents (131). In two trials of patientswithout albuminuria or hypertension,one including peoplewith type 1 diabetes(132) and the other type 2 diabetes (133),RAS inhibitors did not prevent the de-velopment of diabetic glomerulopathyassessed by kidney biopsy. Therefore, RASinhibitors are not recommended for pa-tientswithout hypertension to prevent thedevelopment of diabetic kidney disease.

CONCLUSIONS

Hypertension is a strong, modifiable riskfactor for the macrovascular and micro-vascular complications of diabetes. Ro-bust literature demonstrates the clinicalefficacy of lowering blood pressure, withcardiovascular and microvascular benefitsdemonstrated for multiple classes of anti-hypertensivemedications. Strong evidencefrom clinical trials and meta-analyses sup-ports targeting bloodpressure reduction toat least ,140/90 mmHg in most adultswith diabetes. Lower blood pressure tar-gets may be beneficial for selected pa-tients with high cardiovascular diseaserisk if they can be achieved without un-due burden, and such lower targets maybe considered on an individual basis. Inaddition to lifestyle modifications, multi-ple medication classes are often neededto attain blood pressure goals. ACE inhib-itors, ARBs, dihydropyridine CCBs, andthiazide-like diuretics have been demon-strated to improve clinical outcomes andare preferred for blood pressure control.For patients with albuminuria, an ACE in-hibitor or ARB should be part of the anti-hypertensive regimen. Treatment shouldbe individualized to the specific patientbased on their comorbidities; their antic-ipated benefit for reduction in ASCVD,heart failure, progressive diabetic kidneydisease, and retinopathy events; and their

risk of adverse events. This conversationshould be part of a shared decision-making process between the clinicianand the individual patient.

FUTURE UPDATES

As more evidence becomes available toguide the assessment and treatment ofhypertension among people with diabe-tes, updated, refined, and additional rec-ommendations will be published in theannual ADA “Standards of Medical Carein Diabetes,” available from https://professional.diabetes.org/content/clinical-practice-recommendations.

Acknowledgments.Wewouldverymuch like toexpress our gratitude and thanks to Erika GebelBerg of the ADA for her help in writing themanuscript drafts and coalescing informationfrom all the authors.Funding and Duality of Interest. I.H.d.B. hasbeen a consultant for Boehringer Ingelheim andIronwood Pharmaceuticals, and his institution hasreceived research equipment and supplies fromMedtronic and Abbott. S.B. has received researchgrants from the National Heart, Lung, and BloodInstitute and Abbott Vascular; has been on advi-sory boards for Pfizer, AstraZeneca, and TheMed-icines Company; and has received speaker feesfrom Merck, Abbott, Pfizer, and Abbott Vascular.A.B. has received honoraria from Fukuda-Denshi.E.D.M. has received an honorarium from SiemensHealthcare Diagnostics for being a blinded eventsadjudicator in a clinical trial unrelated to the sub-ject of this article (i.e., it was not related to eitherhypertension or diabetes). P.M. has received re-search support and honorarium from Amgen. P.R.has been a steering committee member for AStudy to Evaluate the Effect of Dapagliflozin onRenal Outcomes and Cardiovascular Mortality inPatients With Chronic Kidney Disease (DAPA-CKD)(AstraZeneca) and Efficacy and Safety of Finere-none in Subjects With Type 2 Diabetes Mellitusand the Clinical Diagnosis of Diabetic Kidney Dis-ease (FIGARO)/Efficacy and Safety of Finerenonein Subjects With Type 2 Diabetes Mellitus and Di-abetic Kidney Disease (FIDELIO) (Bayer) and hasreceived consultancy and/or speaking fees (all hon-oraria to his institution) from AbbVie, Astellas, As-traZeneca, Bayer, Boehringer Ingelheim, Eli Lilly,and Novo Nordisk. S.Z. has been a consultant forAstraZeneca/Bristol-Myers Squibb Australia,Janssen-Cilag, Merck Sharp & Dohme, Novo Nor-disk, Sanofi Australia, and Servier International.G.B. has been a principal investigator on FIDELIO(Bayer), a steering committee member for Evalu-ation of the Effects of Canagliflozin on Renal andCardiovascular Outcomes in Participants With Di-abetic Nephropathy (CREDENCE) (Janssen) andStudy Of Diabetic Nephropathy With Atrasentan(SONAR) (AbbVie), and a consultant for Merck, Re-lypsa, Vascular Dynamics, GlaxoSmithKline, Bayer,Janssen, and AbbVie. No other potential conflicts ofinterest relevant to this article were reported.

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