What are the ADA guidelines on managing hypertension in type 1 diabetes mellitus (DM)?

Updated: Oct 08, 2021
  • Author: Romesh Khardori, MD, PhD, FACP; Chief Editor: George T Griffing, MD  more...
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Guidelines published in 2017 by the American Diabetes Association on managing hypertension in patients with diabetes state the following [192, 193] :

  • Blood pressure should be measured at every routine clinical care visit; patients found to have an elevated blood pressure (≥140/90 mm Hg) should have blood pressure confirmed using multiple readings, including measurements on a separate day, to diagnose hypertension
  • All hypertensive patients with diabetes should have home blood pressure monitored to identify white-coat hypertension
  • Orthostatic measurement of blood pressure should be performed during initial evaluation of hypertension and periodically at follow-up, or when symptoms of orthostatic hypotension are present, and regularly if orthostatic hypotension has been diagnosed
  • Most patients with diabetes and hypertension should be treated to a systolic blood pressure goal of < 140 mm Hg and a diastolic blood pressure goal of < 90 mm Hg
  • Lower systolic and diastolic blood pressure targets, such as < 130/80 mm Hg, may be appropriate for individuals at high risk for cardiovascular disease if they can be achieved without undue treatment burden
  • For patients with systolic blood pressure >120 mm Hg or diastolic blood pressure >80 mm Hg, lifestyle intervention consists of weight loss if the patients are overweight or obese; a Dietary Approaches to Stop Hypertension (DASH)–style dietary pattern, including reduced sodium and increased potassium intake, increased fruit and vegetable consumption, moderation of alcohol intake, and increased physical activity
  • Patients with confirmed office-based blood pressure ≥140/90 mm Hg should, in addition to lifestyle therapy, have timely titration of pharmacologic therapy to achieve blood pressure goals
  • Patients with confirmed office-based blood pressure ≥160/100 mm Hg should, in addition to lifestyle therapy, have prompt initiation and timely titration of two drugs or a single-pill combination of drugs demonstrated to reduce cardiovascular events in patients with diabetes
  • Treatment for hypertension should include drug classes demonstrated to reduce cardiovascular events in patients with diabetes: angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), thiazide-like diuretics, or dihydropyridine calcium channel blockers; multiple-drug therapy is generally required to achieve blood pressure targets (but not a combination of ACE inhibitors and ARBs)
  • An ACE inhibitor or ARB, at the maximum tolerated dose indicated for blood pressure treatment, is the recommended first-line treatment for hypertension in patients with diabetes and a urine albumin-to-creatinine ratio of ≥300 mg/g creatinine or 30–299 mg/g creatinine; if one class is not tolerated, the other should be substituted
  • For patients treated with an ACE inhibitor, ARB, or diuretic, serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored
  • Pregnant women with diabetes and preexisting hypertension or mild gestational hypertension with systolic blood pressure < 160 mm Hg, diastolic blood pressure < 105 mm Hg, and no evidence of end-organ damage do not need to be treated with pharmacologic antihypertensive therapy
  • In pregnant patients with diabetes and preexisting hypertension who are treated with antihypertensive therapy, systolic or diastolic blood pressure targets of 120-160/80-105 mm Hg are suggested in the interest of optimizing long-term maternal health and fetal growth

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