New concepts in blood pressure-lowering management in diabetic patients: the case for early ACE inhibitor combination therapy with diuretics

The incidence of potential drug–drug interactions in elderly patients with arterial hypertension

“…Fortunately, they do not appear to have important clinical consequences [27]. Concomitant therapy with ACEI or angiotensin II receptor blockers and diuretics is of key importance, and it has been proposed to start treatment of hypertension in diabetic patients with combination therapy in order to avoid postponement of effective treatment with the aim of normalising blood pressure [28].…”

Treating hypertension while protecting the vulnerable islet in the cardiometabolic syndrome

“…Outcome data related to newonset T2DM, possible mechanisms by which different classes of agents promote or prevent T2DM, and treatment recommendations are summarized in Table 4, Table 5, and Table 6. Table 4 presents the results of major outcome trials [7,[63][64][65][66][67][68][69][70][71][72][73][74][75][76]; Table 5 summarizes actions of the different classes of antihypertensive agents that may contribute to their effects on T2DM; Table 6 lists treatment recommendations supported by individual study results [7,[77][78][79][80][81][82][83][84][85]. A network meta-analysis (which accounts for both direct and indirect comparisons between classes of drugs) of 22 randomized clinical trials, involving 143,153 participants, was conducted to estimate the relative odds of developing T2DM with an initial class of antihypertensive drug [86].…”

“…Because older β-blockers, may lead to the development of diabetes, clinicians should be cautious in prescribing early combination therapy with these agents for patients at increased risk for T2DM [95]. Some researchers advocated early combination therapy with a thiazide diuretic and an ACE inhibitor or ARB because these newer agents may counteract some of the limitations of the thiazide diuretics [79][80][81]. However, controlled outcome trials have not yet assessed these combinations [7].…”

“…Thiazide diuretics • Use the lowest effective dose [77] • Increase diabetes surveillance in treated patients [78] • Avoid routine combination use of a thiazide diuretic and β-blocker in the early management of hypertension, especially in patients at increased risk for diabetes [81] • Consider early combination therapy with a thiazide diuretic and ACE inhibitor or ARB [79][80][81] β-Blockers • Increase surveillance for diabetes in patients treated with first-or second-generation agents [78] • Use a vasodilating agent (eg, carvedilol) for patients with the CMS [82] CCBs • Consider prescribing a CCB with an RAAS inhibitor for patients requiring combination therapy α-Adrenergic blockers • Avoid first-line therapy with an α-adrenergic blocker, even for patients with the CMS [7] • Consider prescribing an α-adrenergic blocker as adjunctive therapy for patients with treatment-resistant hypertension and impaired glucose metabolism [83] RAAS inhibitors • Choose an ACE inhibitor or ARB as the primary agent for patients with the CMS, especially when impaired glucose tolerance is present [84] ACE inhibitors • Weigh the demonstrated effectiveness of the ACE inhibitors in decreasing the incidence of diabetes against their less-than-ideal safety/tolerability profile ARBs • Consider both the proven effectiveness of the ARBs in preventing or delaying diabetes and their excellent safety/ tolerability profile when prescribing an antihypertensive agent…”

Towards improving the clinical assessment and management of human hypertension: an overview from this Journal

“…Agents that block the RAAS reduce proteinuria and microalbuminuria, lower BP and slow the progression of proteinuric kidney disease, and the use of ACE inhibitor/ARB combination therapy in hypertensive kidney disease may be one therapeutic option. 22,23 In contrast to microalbuminuria, the role of serum uric acid in the context of adverse cardiovascular events in hypertensive subjects is more controversial. Indeed, Tsioufis et al 24 demonstrate that that serum uric acid levels were linked to high BPs, but there was discrepancy in relation to other indices Step 1…”