Diabetes and Hypertension Treatment and Management
Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Diabetes and High Blood Pressure article more useful, or one of our other health articles.
Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
This article aims to provide a simple management plan for the management of people with diabetes mellitus who also have raised blood pressure (BP). It is based mainly on the current National Institute for Health and Care Excellence (NICE) recommendations. See also the Hypertension and Hypertension Treatment articles.
Patients with type 2 diabetes mellitus have a considerably higher risk of cardiovascular morbidity and mortality and are disproportionately affected by cardiovascular disease. Most of this excess risk is associated with high prevalence of well-established risk factors such as hypertension, dyslipidaemia and obesity in these patients[1, 2]. Hypertension plays a major role in the development and progression of microvascular and macrovascular disease in people with diabetes.
Early intervention and targeting multiple risk factors with both lifestyle and pharmacological strategies give the best chance of reducing macrovascular complications in the long term.
Antihypertensive therapies may promote the development of type 2 diabetes mellitus. Studies indicate that the use of angiotensin-converting enzyme (ACE) inhibitors and angiotensin-II receptor antagonists (AIIRAs) leads to less new-onset diabetes compared to beta-blockers, diuretics and placebo.
- Hypertension is more prevalent in patients with type 2 diabetes than in those who don't have diabetes.
- It is estimated that the prevalence of arterial hypertension (BP greater than 160/95 mm Hg) in patients with type 2 diabetes is in the range of 40-50%.
- Adults who have both diabetes and hypertension have more kidney disease and atherogenic risk factors including dyslipidaemia, hyperuricaemia, elevated fibrinogen and left ventricular hypertrophy.
Measuring blood pressure
Measure standing as well as seated blood pressure. In people with a significant postural drop or symptoms of postural hypotension, treat to a blood pressure target based on standing blood pressure.
Measure blood pressure at least annually in an adult with type 2 diabetes without previously diagnosed hypertension or renal disease.
Provide lifestyle advice (diet and exercise) at the same time. See also the separate Diabetes Diet and Exercise article.
NICE recommends blood pressure management at 135/85 mm Hg for adults with type 1 diabetes. If they have albuminuria or two or more features of metabolic syndrome, recommend blood pressure management is at 130/80 mm Hg.
Reduce other risks of cardiovascular disease and other complications of diabetes - eg, smoking cessation, weight reduction, improvement of glycaemic control, and management of hyperlipidaemia.
A Cochrane review found that evidence from randomised trials does not support BP targets any lower than 130/85 mm Hg for people with diabetes.
- Offer an ACE inhibitor or an angiotensin-2 receptor blocker (ARB) to adults starting step 1 antihypertensive treatment who have type 2 diabetes. (NB: for adults of black African or African-Caribbean family origin, consider an ARB in preference to an ACE inhibitor.)
- If hypertension remains uncontrolled with an ACE inhibitor or ARB, offer the choice of a calcium-channel blocker (CCB) or a thiazide-like diuretic.
- If hypertension is still not controlled, offer a combination of an ACE inhibitor or ARB, a CCB and a thiazide-like diuretic.
- If hypertension is not controlled in adults taking the optimal tolerated doses of an ACE inhibitor or an ARB plus a CCB and a thiazide-like diuretic:
- Regard them as having resistant hypertension.
- Confirm elevated clinic blood pressure using ambulatory or home blood pressure recordings. Assess for postural hypotension.
- For people with confirmed resistant hypertension, consider adding a fourth antihypertensive drug or seeking specialist advice.
- Consider further diuretic therapy with low-dose spironolactone if blood potassium level is 4.5 mmol/L or less.
- Consider an alpha-blocker or beta-blocker if blood potassium level is more than 4.5 mmol/L.
- If blood pressure remains uncontrolled in people with resistant hypertension taking the optimal tolerated doses of four drugs, seek specialist advice.
NB: always check safety and appropriate use of each medication for each individual patient - eg, pregnancy, breastfeeding and reduced renal function.
Further reading and references
Type 2 diabetes in adults: management; NICE Guidance (December 2015 - last updated June 2022)
Diabetes - type 2; NICE CKS, November 2021 (UK access only)
Colosia AD, Palencia R, Khan S; Prevalence of hypertension and obesity in patients with type 2 diabetes mellitus in observational studies: a systematic literature review. Diabetes Metab Syndr Obes. 2013 Sep 176:327-38. doi: 10.2147/DMSO.S51325.
Martin-Timon I, Sevillano-Collantes C, Segura-Galindo A, et al; Type 2 diabetes and cardiovascular disease: Have all risk factors the same strength? World J Diabetes. 2014 Aug 155(4):444-70. doi: 10.4239/wjd.v5.i4.444.
Rizos CV, Elisaf MS; Antihypertensive drugs and glucose metabolism. World J Cardiol. 2014 Jul 266(7):517-30. doi: 10.4330/wjc.v6.i7.517.
Lorber D; Importance of cardiovascular disease risk management in patients with type 2 diabetes mellitus. Diabetes Metab Syndr Obes. 2014 May 237:169-83. doi: 10.2147/DMSO.S61438. eCollection 2014.
Grimm C, Koberlein J, Wiosna W, et al; New-onset diabetes and antihypertensive treatment. GMS Health Technol Assess. 2010 Mar 166:Doc03. doi: 10.3205/hta000081.
Hypertension in adults: diagnosis and management; NICE (August 2019 - last updated March 2022)
Type 1 diabetes in adults: diagnosis and management; NICE Guidelines (August 2015 - last updated August 2022)
Arguedas JA, Leiva V, Wright JM; Blood pressure targets for hypertension in people with diabetes mellitus. Cochrane Database Syst Rev. 2013 Oct 3010:CD008277. doi: 10.1002/14651858.CD008277.pub2.
British National Formulary (BNF); NICE Evidence Services (UK access only)