• Hypertension is more commonly prevalent in a diabetic than in a non diabetic;

• It is present in more than 50% of patient with NIDDM and may or may not be accompanied by renal damage.

• It is major risk factor for the development of macro/micro vascular disease in diabetics.

• Although increased cardiovascular risk has been demonstrated in adult diabetic subject with pressure slightly greater than 130/80 mm Hg, the decision to treat mildly elevated levels of blood pressure must rest on clinical grounds in each individual.

• Isolated systolic hypertension is more common in a diabetic than in a non diabetic and is a risk factor for macrovascular disease, but treatment should be individualised.

• In diabetics, the high blood pressure may be due to secondary causes which must be carefully considered and ruled out.

PRIMARY MEASURE (NON DRUG MANAGEMENT)

• The selection of an appropriate drug regimen for the management of hypertension in diabetics entails special consideration as many of the front line drugs have side effects which are detrimental to a diabetic.
  
  A) Angiotensin converting enzyme (ACE) inhibitors:
  

• Possibly drug of first choice in diabetics

• Have beneficial effect on microalbuminuria

• Improve ventricular function, especially in patients with ejection fraction < 45

• Reduce mortality and morbidity in patients with post-myocardial infarction

• Risk of hypotension and hyperkalemia

• Increased risk of renal impairment in patients with: salt depletion (high dose diuretics), renal artery stenosis, existing renal damage, and patients taking interacting drugs (eg. Non steroidal anti-inflammatory agents)

• Essential to closely monitor renal functions and serum electrolytes 1-2 weeks after starting therapy and at regular intervals thereafter; to be discontinued if serum creatinine rises after initiation of therapy
  
  B) Calcium-channel blockers:
  

• Beneficial in managing hypertension in diabetics

• Minimal effects on metabolic profile

• Side effects such as flushing & edema may be problematic

• Renal function needs monitoring

• They may increase proteinuria

• Recent evidence suggests that it is better to use the newer calcium channel blockers such as amlodepin
  C) Beta-blockers:

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• If used, only the cardioselective drugs, in small doses to be prescribed

• May adversely affect lipid profiles and glucose levels

• May cause problems in hypoglycemia counter-regulation and lead to hypoglycemia unawareness
  
  D) Alpha-blockers
  

• Minimal affect on metabolic profile

• May improve lipid profile

• Improve insulin sensitivity

• May be drug of choice in elderly male patients with benign prostatic enlargement

• Risk of severe postural hypotension (first dose phenomenon), but this is possibly due to starting with large initial dose
  
  E) Methyldopa:
  

• Not advisable for use in diabetics

• Associated with unacceptable side effects

• It should not be considered for routine use in diabetics
  
  F) Thiazide diuretics:
  

• Not advisable for use in diabetics

• Have significant adverse effect on glucose levels, especially in presence of hypokalemia

• Adverse effect on lipid profile with raised Tg and TC

• May cause hypokalemia

• Can cause severe salt depletion, especially with high doses

• If prescribed, use in very small doses and monitor electrolytes, lipid and glycemic parameters regularly.
  
  G) Hydrallazine:
  

• Not advisable for use in diabetics.