Treatment strategies for hypertension in patients with type 1 diabetes

ABSTRACT

Introduction

Type 1 diabetes mellitus (T1DM) is a chronic, autoimmune disease that is characterized by total absence of insulin production. Hypertension is a common comorbidity in T1DM with complex pathophysiology, while it is also a well-recognized risk factor for the development of cardiovascular disease (CVD), as well as other microvascular diabetic complications.

Areas covered

The purpose of this review is to present the current definitions, epidemiological data and prevalence rates of hypertension in T1DM, as well as to describe current therapeutic options.

Expert opinion

Hypertension affects around a third of the type 1 diabetic population, with higher prevalence rates in older individuals with longer disease duration. Although hypertension affects a substantial proportion of T1DM individuals, blood pressure control rates are disappointingly low. Alongside lifestyle modification, antihypertensive treatment should be initiated in those with blood pressure above 140/90 mmHg, with a systolic blood pressure target of 130 mmHg and lower, if tolerated. In those with established CVD or diabetic nephropathy, systolic blood pressure targets below 130 mmHg should be pursued. Initial pharmacotherapy should consist of a renin-angiotensin-aldosterone system inhibitor. There is an urgent need for good quality data regarding proper antihypertensive treatment initiation, optimal BP targets and optimal antihypertensive treatment for better clinical outcomes.

KEYWORDS:

• Angiotensin-converting enzyme inhibitors
• angiotensin receptor blockers
• hypertension
• renin-angiotensin-aldosterone system inhibitors
• SGLT2 inhibitors
• type 1 diabetes

Article highlights

• Hypertension affects around a third of type 1 diabetic individuals

• Antihypertensive treatment should be initiated promptly in grade 1 hypertension. Those with established cardiovascular disease should be treated when blood pressure is within the high-normal range

• Blood pressure should be lowered towards 130/80 mmHg and lower, if well tolerated, while in high-risk individuals it should be targeted below 130/80 mmHg

• Lifestyle measures should always be implemented, even in those individuals with blood pressure within the high-normal range

• A two-drug combination therapy consisted of a renin-angiotensin system inhibitor and a calcium channel blocker or a thiazide/thiazide-like diuretic is the recommended initial pharmacotherapy

• Randomized controlled trials assessing blood pressure thresholds for treatment initiation and therapeutic goals are lacking

This box summarizes key points contained in the article.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript was not funded.