english.prescrire.org > Spotlight > Archives : 2017 > Hypertension and diabetes: if chlortalidone is unavailable, an ACE inhibitor should be the drug of choice

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Hypertension and diabetes: if chlortalidone is unavailable, an ACE inhibitor should be the drug of choice

Hypertension treatment in diabetes patients aims to reduce the risk of complications: cardiovascular events, end-stage renal failure, deterioration of eyesight.

Patients with diabetes are exposed to arterial damage, including coronary artery disease and stroke, and damage to the blood capillaries, particularly in the retina (retinopathy, the cause of decreased visual acuity, even blindness), and in the kidneys (nephropathies, leading to kidney failure).

In line with assessment data, it is reasonable to aim for a resting blood pressure of less than 140/90 mmHg in diabetes patients, taking into account the risks associated with the build-up of antihypertensive drugs.

In 2016, assessment data in diabetes patients without renal failure indicates similar choices to those made in the absence of diabetes: when chlortalidone single agent is unavailable, an ACE inhibitor such as captopril, lisinopril or ramipril is the drug of choice.

In diabetes patients with high blood pressure and severe renal failure, thiazide diuretics are ineffective and should be avoided. An ACE inhibitor or an angiotensin receptor blocker (sartan) such as irbesartan or losartan are the first-line options, especially to reduce the risk of progression to end-stage renal disease. The combination of an ACE inhibitor + sartan should be avoided.

When a single drug is not sufficient to attain the target blood pressure values, an ACE inhibitor + diuretic thiazide or ACE inhibitor + amlodipine appear to be the most appropriate choices.

©Prescrire 1 June 2017

"Hypertension and diabetes. If chlortalidone is unavailable, an ACE inhibitor is the first choice" Prescrire Int 2017; 26 (183): 155-160. (Pdf, subscribers only).
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