Blood pressure ≥ 160/100 mm Hg should be treated with lifestyle therapy and prompt initiation and timely titration of two drugs or a single-pill combination of drugs.
Multidrug therapy is generally required to achieve blood pressure targets—but ACE inhibitors and ARBs should not be used in combination due to the increased risk for adverse effects.
Firstline therapy is an ACE inhibitor or an ARB, at the maximum tolerated dose, in patients with diabetes and a urine albumin-to-creatinine ratio ≥ 30 mg/g.
Monitoring of estimated glomerular filtration rate and serum potassium levels is needed in patients treated with an ACE inhibitor, ARB, or diuretic.1
Patients with diabetes who have a blood pressure ≥ 140/90 mm Hg despite treatment that includes lifestyle management, two antihypertensives, and a diuretic, or who achieve blood pressure control with four or more medications, are considered to have resistant hypertension.1,5 Factors such as pseudoresistance (lack of medication adherence or poor measurement technique), masked hypertension, and white coat hypertension should be ruled out in making the diagnosis of resistant hypertension. Once these have been excluded, patients should be referred for a workup of their resistant hypertension to evaluate causes of secondary hypertension. These can include endocrine issues, renal arterial disease, edema in advanced kidney disease, hormones, and drugs such as NSAIDs and decongestants.1
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