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Hypertension and Diabetes: Treatment Goals

Posted Aug 24 2008 1:49pm
MABEL JONG: Hello, and welcome to our webcast. I'm Mabel Jong. For diabetes patients, changes in blood sugar levels can mean the difference between well-being and serious danger, so controlling these levels is a crucial part of daily life. But a large percentage of people with diabetes also develop high blood pressure, or hypertension, which is equally dangerous.

Joining me today to discuss the treatment of hypertension in diabetes patients are Dr. Dominic Sica from the Medical College of Virginia Campus of Virginia Commonwealth University, and also Dr. William White from the University of Connecticut School of Medicine.

If you found out that you have both hypertension and diabetes, what are your treatment goals?

WILLIAM WHITE, MD: When you have both high blood pressure and diabetes, it's kind of like a double whammy, to tell you the truth, because you are now at enhanced risk for coronary disease, vascular disease, kidney disease and so forth. So we've become more aggressive in recent years, because results of large studies suggest normalization is more important than ever before. So we are now trying to shoot for blood pressure that is normal i.e., less than 130 for the systolic pressure, which is the top number, and less than 80. If you have significant renal or kidney disease, we're even looking for lower values than that, if possible i.e., less than 125 or 75.

You've got to do the same thing with blood sugar. You have to keep that under control. We're now looking for blood sugars that are in the normal range. We're now looking for blood sugars that are around 100, 110 mg per cent instead of 125 or 150, like we used to accept in the old days. And in addition to that, we use this test called the glycohemoglobin, or hemoglobin AIc, which kind of looks at the pattern of control of blood sugar for the last two or three months. That's a percentage, and so we look at that now as a value that we're trying to get down to around 6%, if possible.

MABEL JONG: What's the first step in achieving some of those levels?

WILLIAM WHITE, MD: It's going to require the non-drug options such as exercise, diet, watching your salt intake and so forth, but in that case we've learned that you really need to have multiple drugs used in a thoughtful combination so that you can take most of the stuff in the first part of the day or at night, and not having to take medications throughout the day.

MABEL JONG: Now, Dr. Sica, would you agree that you would go right for the medications first, or should you try diet and exercise first?

DOMINIC SICA, MD: You always try it, but it may be simultaneous or first. So even though you may start the medicine, you almost always implement a lifestyle management plan that incorporates into it appropriate dietary modifications and exercise pattern. Those are key issues, so I don't think we separate them.

MABEL JONG: So basically, with certain lifestyle and diet modifications, it sounds like these are diseases that you can control, as opposed to something like cancer.

WILLIAM WHITE, MD: This is a good way to think of this: This is not a curable disorder, but a treatable disorder, and that is, in fact, a big difference. In many cases, though, it's a serious problem, because the end result of having uncontrolled diabetes and uncontrolled hypertension is just as bad as having uncontrollable or untreated cancer.

MABEL JONG: Do we know, Dr. Sica, what's more important, to control blood sugar or blood pressure?

DOMINIC SICA, MD: We probably should never separate those two, although some information suggests there is an attendant greater benefit in a diabetic to blood pressure reduction for certain complications, and for others a benefit from tight blood sugar control. One should never argue the point to try and prefer one versus the other.

MABEL JONG: Are all people who have both conditions being treated with blood pressure medicine?

DOMINIC SICA, MD: It is very uncommon for a hypertensive diabetic being treated for their high blood sugars not to be receiving blood pressure medication for their hypertension.

MABEL JONG: How many different types of medications are people with both hypertension and diabetes typically on?

WILLIAM WHITE, MD: Well, I would say on average that you would be on two or three blood pressure-lowering drugs and approximately two agents which lower the blood sugar, if you're not on insulin. So that's probably about five drugs per patient, if the condition is relatively controllable and relatively mild to moderate. In some of our more severe patients, you can almost double that.

MABEL JONG: And are there side effects, like being drowsy at certain times of the day?

WILLIAM WHITE, MD: Every class of anti-hypertensive drug has some of its own distinct little side effects. Fortunately, the medications have gotten so much better during the last 20 years that we actually see many of the new drugs having no more side effects than placebo pills or sugar pills.

DOMINIC SICA, MD: I would also maybe add that the problem of polypharmacy or multiple prescriptions is such now that most physicians' knowledge of how to give a drug and the wide range of drugs within a specific drug class allow things to be given in a way where side effects are really minimized.

MABEL JONG: Can you outline some success rates from using these drugs, Dr. Sica?

DOMINIC SICA, MD: The success is both immediate and then it's realized long term. The immediate gain is by blood pressure coming under control. The long-term gain will never really be identified in a specific patient, but will be identified in a population sense, so being exposed to these medicines means a lesser risk of developing coronary artery disease, congestive heart failure and likely a lesser progression onto various elements of chronic renal failure.

MABEL JONG: Closing comments, Dr. White?

WILLIAM WHITE, MD: We've learned an awful lot just in the last couple of years about the management of the hypertensive patient with diabetes. We've learned specific new information about certain classes of drugs, and therefore we are able to provide to patients a more refined drug treatment plan, even though it's a lot of drugs, that will actually reduce their morbidity, and that's a very positive thing, considering what we knew a few years ago.

MABEL JONG: A last word from you, Dr. Sica?

DOMINIC SICA, MD: I think the more information we can get to patients about these diseases, so we self-empower them to became active participants in their own health care plan, is the best way we're going to solve this problem. If you educate the patient, you very importantly create the basis for future success with the therapies that you apply.

MABEL JONG: Dr. Sica, Dr. White, thanks for joining us today. And thank you for watching our webcast. I'm Mabel Jong.

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