Drug treatment of hypertension in older patients with diabetes mellitus

ABSTRACT

Introduction: Hypertension is more prevalent in the elderly (age>65 years) diabetic population than in the general population and shows an increasing prevalence with advancing age. Both diabetes mellitus (DM) and hypertension are independent risk factors for cardiovascular (CV) related morbidity and mortality. Optimal BP targets were not identified in elderly patients with DM and hypertension.

Areas covered: In this review article, the authors briefly discuss the pathophysiology of hypertension in elderly diabetics, present evidence with various antihypertensive drug classes supporting the treatment of hypertension to reduce CV events in older diabetics, and then discuss the optimal target BP goals in these patients.

Expert opinion: Clinicians should have a BP goal of less than 130/80 mm in all elderly patients with hypertension and DM, especially in those with high CV-risk. When medications are required for optimal BP control in addition to lifestyle measures, either thiazide diuretics, angiotensin-converting-enzyme inhibitors, angiotensin receptor blockers, or calcium channel blockers should be considered as initial therapy. Combinations of medications are usually required in these patients because BP control is more difficult to achieve in diabetics than those without DM.

KEYWORDS:

• Hypertension
• diabetes mellitus
• elderly patients
• target blood pressure

Article highlights

• Accumulating evidence from randomized trials and meta-analyses support a lower blood pressure goal in the elderly population.

• Elderly hypertensive diabetics have a multitude of cardiovascular comorbidities and will benefit from appropriate blood pressure control.

• A blood pressure goal of less than 130/80 mm Hg should be achieved in elderly diabetics to reduce cardiovascular morbidity and mortality.

• Automated validated devices must be used for measuring blood pressure.

• Lifestyle modifications should be prescribed in all patients.

• When medications are required, thiazide diuretics (especially chlorthalidone), angiotensin-converting-enzyme inhibitors, angiotensin receptor blockers, or calcium channel blockers should be considered as initial therapy. Combinations might be required frequently.

• Beta-adrenergic blockers are second line agents unless specific first line indications for their use exist.

• The anti-hypertensive effects of sodium glucose cotransporter-2 antagonists and glucagon like peptide-1 receptor agonists could have a role in further improving cardiovascular outcomes in elderly hypertensive diabetics.

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

Additional information

Funding

This manuscript has not been funded.