High blood pressure ("hypertension") is a risk factor for strokes, heart attacks, kidney failure, blindness...the list goes on and on.  Because diabetes is also a risk factor for these same ailments, it is crucial that these risk factors be modified.  AGGRESSIVELY! (definitely my favourite word when it comes to diabetes management).  "Good" blood pressure is not good enough.  "Okay" blood pressure is not okay enough.  PERFECT blood pressure is what we are after.  And as noted in my Top Ten List, optimal is generally no higher than 130/80 (quite a change from when I was in medical school back in the late '70's are we were taught to only treat high blood pressure if it was above 160/95!).  The upside...maintaining perfect blood pressure will keep you healthier longer.  The downside...doctors like me ask people with diabetes like you to take yet more pills.  Certainly lifestyle measures (e.g., low salt diet, exercise, caffeine and alcohol restriction, weight loss, etc.) are important, but they are often not enough.  As such, medication is generally necessary for anything other than very mild hypertension.  You can read a good general discussion of high blood pressure (I'm not being immodest...it's not my article).

Drugs for high blood pressure fall into a variety of classes including:

If you have been prescribed an ACE inhibitor you may have been told by someone (other than your doctor) that is must be that you were given this because of high blood pressure.  As it turns out, however, ACE inhibitors are used to treat many different types of health problems and, commonly when it comes to diabetes, not to treat a health problem per se, but to prevent one.  Indeed, we now have very strong evidence that ACE inhibitors have a role in the prevention of diabetes complications such as strokes, heart attacks and kidney failure.  The Canadian Diabetes Association recommends that most people with diabetes be considered for treatment with ACE inhibitors (even if they are in perfect health otherwise).  One particularly important study - the HOPE Study - has shown that for people with diabetes who are 55 years of age or older AND who have at least one other risk factor for heart disease, ACE inhibitor therapy (Altace [ramipril] in this particular case) can substantially reduce the risk of having a heart attack or stroke.  Whether other people with diabetes (i.e., those younger than 55 and/or those with no other risk factors for heart disease) would have a similar benefit remains to be proven.  So, if I have a patient who fits the criteria used in the HOPE Study, I routinely prescribe ACE inhibitors; for those who do not meet these criteria I make my decision on a case by case basis.  Would I place a twenty-five year old with recent onset type 1 diabetes on ACE inhibitors if they have normal blood pressure, normal cholesterol, do not smoke, etc.?  No.  Would I place a sixty year old person with hypertension and longstanding type 2 diabetes on an ACE inhibitor?  You bet.

Having a reasonably large selection of anti-hypertensive agents ("blood pressure medications") to choose from is a real plus.  The many different drugs available means that invariably if one drug isn't working out, we have others to choose from.  So then, how do we decide which one to prescribe? 

Although there is no "right or wrong" choice, the general practice at present is, for people with diabetes and hypertension, to use an ACE inhibitor first.  ACE inhibitors tend to effectively lower blood pressure, are generally tolerated well  (the most common side-effect from these drugs is a dry cough which goes away soon after the medication is withdrawn) and in addition have what is called "renal protective" properties; that is, they protect the kidneys independent of their blood pressure-reducing ability. 

Second choice?  Typically an angiotensin receptor blocker (ARB).  They are newer to the market than ACE inhibitors so we don't know quite as much about them, but the rapidly mounting evidence so far indicates that they are equally good at reducing blood pressure and in protecting the kidneys and, fortunately, don't cause coughing.  So, if you can't tolerate an ACE inhibitor because of coughing, an ARB is a good alternative.  It may well be that within a few years this group of drugs will become the "gold standard" and will have taken over from ACE inhibitors as the "drug of choice" for treating high blood pressure in individuals with diabetes.

So what medicine, you might ask, should you take if your blood pressure is not adequately controlled despite taking an ACE inhibitor or an ARB?  My personal choice is to add a low dose of hydrochlorothiazide.  We used to shy away from thiazide diuretics (eg. hydrochlorothiazide) because of concerns they would adversely affect blood glucose or cholesterol levels, but now that we use lower doses we have found that they tend NOT to worsen glucose or cholesterol levels.  I use doses in the range of 12.5 to 25.0 mg per day of hydrochlorothiazide.  Higher doses are unlikely to provide additional benefit; all higher doses typically do is lead to side effects.  By the way, these low doses of this type of diuretic seldom actually have a significant diuretic effect.

And then?  Well, after that it is a bit of a toss-up.  Beta blockers are often effective, but on occasion can cause problems with reducing the ability to detect low blood sugar levels (a condition called "hypoglycemia unawareness").  Calcium channel blockers are a reasonable choice and I not infrequently will use them.  And if things are still not working out that is usually when I'll bring in my "reserve list" which includes Aldomet or Minipress.

The bottom line ... your blood pressure has to be controlled (no higher than 130/80) and we try to use the minimum number of drugs that will achieve that.  Sometimes that is one drug, but more commonly two and, not infrequently three or four.  A lot of drugs?  You bet.  But if it avoids a stroke or a heart attack, blindness or kidney failure....well, most people would say that it was worthwhile taking that fistful of medicines.