Blood pressure, diabetes and diabetic nephropathy

Despite multiple evidence-based data that diabetic nephropathy is largely preventable and its progression slowed by currently available interventions diabetic patients are often undertreated, especially for the lowering of blood pressure. Recent studies, (HOT Syst-Eur, SHEP, UKPDS, CAPPP, ABCD, HOPE) have confirmed the efficiency of intensively treated blood pressure in reducing morbidity-mortality in this group of patients at high risk. Low blood pressure targets are mandatory, but may not be that easy to achieve, especially in the presence of renal failure. Early prescription of a combination of antihypertensive drugs is often neccessary. Thus, the clinical question relates to the best combination of drugs. Most studies in hypertensive diabetic patients have dealt with 3 classes of antihypertensives drugs: diuretics, beta-blockers and ACE-inhibitors. Diuretics are one of the most efficient hypotensive drugs available for treatment of hypertension in diabetic patients. Their use must be encouraged early in the stepped approach since diabetes is usually associated with mid-volume expansion due to hyperinsulinism and hyperadrenergic state. In spite of the proven benefit of beta-blockers in diabetic patients, these drugs are largely underused. The indications for selective beta-blockers should probably be broadened for most diabetic patients in primary prevention. Beta-blockers are essential in secondary prevention for patients with coronary artery disease and hypertension. ACE-inhibitors are now more and more widely prescribed in diabetic patients at all stages of hypertension and nephropathy, but paradoxally their use has not been validated in Type 2 diabetic nephropathy. When the desired blood pressure target is obtained, cardiovascular outcome and probably also progression of diabetic nephropathy are significantly improved independently of a specific drug. Early combination therapy, including ACE-inhibitors, diuretics and beta-blockers, should be promptly proposed to all hypertensive diabetic patients to achieve low blood pressure and prevent high cardiovascular burden and progression of nephropathy.