DL is a 54-year-old African American man who presents to the clinic for diabetes mellitus (DM) follow-up. His past medical history includes type 2 DM, hypertension, and gout.
His current medications are:
• Metformin, 1000 mg twice daily
• Allopurinol, 300 mg once daily
• Aspirin, 81 mg daily
• Pravastatin, 40 mg daily
Labs are drawn today and include:
• HbA1c level, 6.8%
• Complete metabolic panel: WNL (SCr, 0.7; Na+, 139; K+, 4.6; AST, 23; ALT, 26)
• Uric acid, 5.7 mg/dL
• Urine microalbumin/urine creatinine ratio, 4 mg/g
• Weight, 72 kg
• BMI, 28 kg/m2
• Blood pressure in clinic today, 150/90 mmHg and 152/94 mmHg
• Blood pressure average at last 3 clinic visits: 150/94 mmHg, 138/84 mmHg, 144/86 mmHg
• Last 3 HbA1c measures in the past year: 6.9%, 6.4%, 6.6%
The patient has no known drug allergies, and he quit smoking 1 year ago.
DL receives a diagnosis of hypertension. He notes that he has been making lifestyle changes, specifically following the Dietary Approaches to Stop Hypertension (DASH) diet and increasing his exercise, since being told of his elevated blood pressure at previous visits starting 1 year earlier.
Most appropriate answer: D. Add amlodipine, 5 mg daily
Cardiovascular disease (CVD) is a major contributor to morbidity and mortality in patients with DM. Controlling coexisting conditions, specifically hypertension and dyslipidemia, can help prevent CVD in patients with DM.1 In patients with T2DM, current guidelines recommend controlling blood pressure to a target of 140/90 mmHg.2
This patient has had at least 3 recent elevated blood pressure readings and has tried diet and lifestyle changes; therefore, he is indicated to begin treatment for hypertension. Per the Eighth National Joint Committee (JNC8) guidelines, calcium channel blockers (CCBs) are recommended first-line as monotherapy in African American patients, even in those patients with DM, in the absence of kidney disease. CCBs are very effective at lowering blood pressure across ethnicities. In the ALLHAT trial, they showed no difference in the prevention of cerebrovascular disease, coronary heart disease, combined cardiovascular and kidney outcomes, and overall mortality when compared with diuretics in the prespecified subgroup of black patients, 46% of whom had DM.2,3
Choice A is not recommended. Beta-blockers are no longer recommended as first-line agents in hypertensive patients without an indication (eg, heart failure with reduced ejection fraction). A selective beta-blocker, such as metoprolol, may be less likely to reduce blood pressure than other first-line agents, especially in black patients, making it more difficult to reach treatment goals. In addition, adverse effects, such as fatigue, sexual dysfunction, and changes in glucose level, may limit the use of these agents in patients who have no compelling indication for their use.2,4
Choice B is not recommended. Per JNC8 guidelines, ACE inhibitors are not considered first-line agents as monotherapy in African American patients, even those with DM, who have no history of kidney disease. Our patient DL has not history of kidney disease and his urine albumin/creatinine ratio is normal. This recommendation comes primarily from evidence gained from a prespecified subgroup analysis of black patients in the ALLHAT trial. In that trial, the thiazide-type diuretic chlorthalidone was more effective than ACE inhibitors in improving cerebrovascular disease, heart failure, and combined cardiovascular outcomes. As noted in choice A above, CCBs showed outcomes similar to those of the thiazide diuretics in this population and were more effective than ACE inhibitors at reducing blood pressure. In addition, the ALLHAT study showed a 51% higher rate of stroke in black patients with the use of ACE inhibitors as initial monotherapy than with CCB therapy.2-4
This recommendation may be controversial, particularly when compared with guidelines that recommend ACE inhibitors as initial therapy, but the clinician’s primary goal is to get the patient’s blood pressure controlled and many patients with DM require multiple therapies to reach blood pressure goals. Therefore, ACE inhibitors should and will be included in the regimen as second-line and/or combination agents.2,4
Choice C is not recommended. Although thiazide diuretics are considered first-line agents, especially in African Americans who have hypertension, this patient would not be a candidate because of the presence of gout in his past medical history. Thiazide diuretics can increase uric acid levels and therefore are not considered first-line therapy in patients with gout when other options are available.
Choice E is not recommended. Lifestyle modifications, such as increased exercise, weight loss, and dietary changes (eg, the DASH diet), are important in the treatment of patients with hypertension. Based on this patient’s history, he has made lifestyle improvements over the past year. However, because his blood pressure remains elevated, pharmacotherapy is indicated at this point.2
1. Cardiovascular disease and risk management. Diabetes Care. 2015;38(Suppl 1):S49–S57.
2. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). [Erratum in JAMA. 2014;311:1809.] JAMA. 2014;311:507-520.
3. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). [Erratum in: JAMA. 2004;291:2196.] JAMA. 2002;288:2981-2997.
4. Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and the International Society of Hypertension. J Hypertens. 2014;32:3-15.