Erica Heilman
Most people know that uncontrolled sugar levels in people with diabetes is a sign of trouble. But many people—even those with the disease—are unaware that diabetes is also a risk factor for heart disease and stroke. People with diabetes are twice as likely to suffer from heart disease and five times more likely to suffer from stroke than people without the condition. This risk is greatest for those patients who suffer from both high blood pressure and diabetes.
This pair is apparently not uncommon. Up to 60 % of adults with diabetes have hypertension. Many are unaware they have it, or they are not receiving the treatment they need. And though blood pressure control becomes absolutely critical in people with diabetes, all too often people with diabetes focus entirely on maintaining blood sugar levels, and blood pressure levels run dangerously unchecked.
Below, Dr. Dominic Sica from the Medical College of Virginia Campus of Virginia Commonwealth University, and Dr. William White from the University of Connecticut School of Medicine talk about treatment for this dangerous duo.
What is the major concern about having both diabetes and hypertension?
WILLIAM WHITE, MD: Having both high blood pressure and diabetes is a kind of double whammy. The major issue is that both of them are risks for the development of atherosclerosis—or narrowing of arteries that supply the brain, heart and kidneys. You are at higher risk for coronary disease, vascular disease, kidney disease and a number of other conditions. So the risk of heart attack, stroke and kidney disease are all accentuated fairly dramatically when an individual has both high blood pressure as well as diabetes versus having either of those alone.
What are the treatment goals for people with both hypertension and diabetes?
WILLIAM WHITE, MD: We've become more aggressive in our treatment goals in recent years, because results of large studies suggest normalization is of critical importance. We try 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 as a diastolic pressure (the bottom number). If you have significant renal or kidney disease, we're even looking for target values even lower than that, if possible, i.e., less than 125 systolic and 75 diastolic.
We look for blood sugars that are in the normal range. We want the free plasma glucose to be between 100 and 110 mg/dl. We also use a test called the glycohemoglobin, or hemoglobin AIc, which looks at the pattern of control of blood sugar for the last two or three months. It's a percentage, and we are trying to get down to around 6%, if possible.
Is it possible that diet and exercise can help people reach these levels without medications?
WILLIAM WHITE, MD: Exercise and diet are critical components of treatment, but we've learned that many will need medication as well.
DOMINIC SICA, MD: It is very uncommon for a hypertensive diabetic being treated for their high blood sugars to not be receiving blood pressure medication for their hypertension. Treatment may involve simultaneous medical therapy and attention to lifestyle management. Both are key parts of treatment.
Is one more important to treat than the other—diabetes or hypertension?
DOMINIC SICA, MD: Some information suggests there is an attendant greater benefit to blood pressure reduction in a diabetic for certain complications, and for others a greater benefit from tighter blood sugar control. But there is really no reason they should be separated or prioritized. It is critical to address both the diabetes and the blood pressure.
How many different types of medications do people typically take if they suffer both from hypertension and diabetes?
WILLIAM WHITE, MD: On average, 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 more severe patients, you can almost double that.
Are there side effects to these drugs?
WILLIAM WHITE, MD: Every class of anti-hypertensive drug has its own distinct side effects. Fortunately, the side effect profiles have gotten much better in the last 20 years, and many of the new drugs result in no more side effects than placebo sugar pills.
DOMINIC SICA, MD: Also, doctors are much more skilled at prescribing multiple medications than they once were, and side effects are minimized for this reason.
And what are the ultimate benefits of adhering to a combination of anti-hypertensive drugs?
DOMINIC SICA, MD: The immediate gain is the lowering of the blood pressure. In the longer term, 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.
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 we are now able to provide a more refined drug treatment plan to our patients. Though it requires more drugs, these new approaches actually reduce morbidity and have fewer side effects than some of the older drugs. That's very positive, considering what we knew a few years ago.
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