Strategy and Selection of Drug Therapy139

Prakash C. Deedwania

The coexistence of hypertension and diabetes dramatically and synergistically increases the risk of microvascular and macrovascular complications. Overwhelming evidence supports aggressive treatment of hypertension in diabetic patients. Tight blood pressure control is cost-effective and is more rewarding than glycemic control. The optimal goal of blood pressure control in diabetics should be 130/80 mm Hg. In subjects who have diabetes and renal insufficiency, the blood pressure should be lowered to 125/75 mm Hg to delay the progression of renal failure. The choice of an antihypertensive agent should be based on proven effects on morbidity and mortality rather than on surrogate parameters, such as lipid or glucose. Limited data suggest that an angiotensin-converting enzyme (ACE) inhibitor is the agent of choice, especially in those who have proteinuria or renal insufficiency. b-Blockers can be the first-line agent in diabetics who have coronary heart

v disease. Thiazide diuretics and calcium-channel blockers are the second-line drugs. Angiotensin II-receptor blockers may prove to be as effective as ACE inhibitors in diabetics who have hypertension. a-Adrenergic antagonists should be avoided. Most hypertensive patients require more than one agent to control their blood pressure. There is no evidence to support one combination regimen over others; however, the combination of ACE-I with a thiazide diuretic or a ß-blocker may be the most cost effective regimen.

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