Hypertension and DiabetesWritten by Expert Pharmacist
February 25, 2020
Contributor: Dr. Staci-Marie Norman, PharmD, CDE
According to the Centers for Disease Control (CDC), 33.2% of adults over the age of 20 have measured hypertension (high blood pressure) or are on medication to manage their blood pressure. And of those with hypertension, only 1 in 4 have their blood pressure at target range. In 2017 nearly 500,000 deaths had hypertension as the primary or contributing cause. Hypertension can contribute to microvascular disease that can lead to kidney disease, retinopathy, and peripheral artery disease. It can also lead to heart disease and strokes. Diabetes is a risk factor for these conditions as well.
So, what is hypertension? A blood pressure measurement is made up of two numbers. The first (or top) number is the systolic blood pressure. This is a measurement of our heart at work. The second (or bottom) number is the diastolic blood pressure, and this is a measurement of our heart at rest. Normal blood pressure is considered anything less than 120/80 mmHg. Hypertension is classified as elevated blood pressure, Stage One hypertension, and Stage Two hypertension. Elevated blood pressure is pressure 120-129/140/90 mmHg. The American Diabetes Association (ADA) blood pressure goals for people with diabetes are <140/90 mmHg for those at low risk of heart disease (<15% ten-year risk of heart disease), and <130/80 mmHg for those with higher risk (>15% ten-year risk of heart disease) or with established heart disease.
There are many ways to treat hypertension. First, there are lifestyle modifications. Like blood glucose management, blood pressure may be lowered with weight loss, exercise, and reducing sodium intake. There are also four classes of medications that can be extremely helpful in lowering blood pressure. These classes are ACE inhibitors (ACEi), angiotensin receptor blockers (ARB), calcium channel blockers (CCB), and thiazide diuretics. Examples of the most common medications in each class are:
- ACEi: lisinopril, ramipril, benazepril, enalapril, fosinopril
- ARB: losartan, valsartan, irbesartan, olmesartan, telmisartan
- CCB: amlodipine, nifedipine, felodipine
- Thiazide: hydrochlorothiazide, chlorothiazide, chlorthalidone, indapamide, metolazone
According to the ADA 2020 Standards of Care, any one of these medication classes could be used to treat hypertension between 140-159/90-99 mmHg with no kidney involvement measured by albumin in the urine. If there is kidney involvement, then the best choice of medications would be an ACEi or ARB due to their ability to “protect” the kidney. If the blood pressure is less than 160/100, then initial therapy should be started with two medication classes. If there is no kidney involvement, this would be either ACEi or ARB, CCB, and thiazide. If the kidneys are involved, then an ACEi or ARB needs to be one of the two medications. But, an ACEi and an ARB should never be used together. Monitoring for blood pressure management and side effects is important after being placed on medication. If the medications are being tolerated, but blood pressure is not managed, increased dosing might be warranted, or the addition of a second or even third class of medication may be needed. In the instance of an ACEi or ARB plus CCB and thiazide being taken, and the blood pressure is still not managed, additional medications from the Mineralocorticoid Receptor Antagonist class could be used, but secondary causes of hypertension should also be explored.
You're probably now wondering what you can do to make sure your blood pressure is well managed. First, I would encourage you to monitor your blood pressure. Unfortunately, high blood pressure isn't something that most people can feel until it is extremely high and causing symptoms such as headaches. So monitoring on a routine basis at home isn't a bad idea, especially if you are someone who is nervous at the doctor's office and might experience what we call "white coat" syndrome - where the blood pressure is slightly elevated over your typical level when visiting the doctor. If you are monitoring at home, be sure to get a good digital monitor with a cuff that fits your arm correctly. You will know this by feeling for the rubber bladder inside the cuff. If this bladder wraps your arm at least 80% around, then this is a good fit. If it overlaps, it is too big. Being too small can give you a false high reading, and being too big can give you a false low reading. Cuffs do come in multiple sizes, so make sure you buy a machine that allows you to interchange the cuff, and that you have the right size cuff. You should always sit and rest quietly for 5 minutes prior to taking your blood pressure. You should not smoke or drink caffeine 30 minutes prior to taking your blood pressure, and you should be seated with both feet on the floor and arm at heart level resting on a table for the most accurate measurement.
Second, life-style modifications are key to success. Making sure you are maintaining or losing weight, if needed, can be extremely helpful. A low sodium diet can help prevent hypertension and lower your blood pressure if already elevated. Avoiding processed foods can be a huge step in lowering the sodium in your diet. It is recommended to have no more than 2300mg of sodium per day and possibly lower in some situations. If you look at some frozen dinner labels, they can contain anywhere from half to almost all the daily recommended sodium, so keep an eye on what you are consuming. Exercise is also very helpful in lowering blood pressure. It is recommended that we get at least 20 minutes of activity most days of the week for heart health, but a 20-minute walk will also work to lower your blood pressure and blood glucose! Smoking is also not good for blood pressure management, so I would encourage smoking cessation for many health reasons. If you have questions about different cessation products, ask your doctor or pharmacist.
Third, if you are prescribed medication for hypertension – take the medication! It is estimated that 50% of people taking medications do not take it as prescribed, and approximately 50% will completely stop taking a prescribed medication within one year. For hypertension specifically, this is estimated to contribute to 89,000 preventable deaths annually. It is also estimated that taking medications as prescribed has a health savings of anywhere from $4000 to $8000 annually for an individual with a chronic illness. These are some good reasons to take that little pill. Most people stop taking their medications due to either cost or adverse reactions. Please talk with your doctor or pharmacist if either of these is affecting your ability to take your medication. There are many cost-effective options and alternative agents that may not have the same adverse effect, but if you don't speak up, how would your doctor know? Your healthcare team is just that – part of your team to help you be as healthy as possible.
Dr. Staci-Marie Norman, PharmD, CDE received her bachelors from Purdue University (’94) and her Doctor of Pharmacy from the University of Oklahoma (’96). In 2000 Dr. Norman added to her credentials by becoming a Certified Diabetes Educator. She is currently the Clinical Coordinator and staff pharmacist for Martin’s Pharmacy. Dr. Norman is a national faculty member for the American Pharmacist Association, teaching certificate programs in both diabetes and cardiovascular disease. She serves on the advisory board that oversees development and revision of these programs. Along with teaching and development responsibilities for APhA, Dr. Norman serves as a peer reviewer for research grants and publication submission. Dr. Norman has also spoken for Abbott, Bayer, Lilly, Mannkind, and Lifescan as a diabetes specialist.