Treatment selection considerations for the hypertensive diabetic patient

Hypertension occurs with twice the frequency in the diabetic population as compared with the general nondiabetic population. Treatment of hypertension in diabetics can be complicated by diabetic complications and the potential for adverse effects from selected antihypertensive drugs. A rational approach to antihypertensive therapy in diabetics with or without concurrent diabetic complications incorporates a "stepped" approach to therapy that includes alternative step 1 agents (eg, angiotensin-converting enzyme inhibitors and calcium channel blockers) rather than traditional agents (eg, diuretics and beta-blockers). Evolving evidence with angiotensin-converting enzyme inhibitors reveals that they do not exacerbate complications of diabetes mellitus and also may arrest or slow the progression of diabetic nephropathy. Treatment algorithms for a stepped approach to the management of the hypertensive diabetic patient are proposed.