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Hypertension Pathway

Blood Pressure Treatment Pathway
For Patients with Diabetes

Treat to <130/80 (in renal disease consider <120/70)

Protocol

Most patients will require an angiotensin converting enzyme inhibitor, a diuretic and at least one other blood pressure lowering agent, therefore consider using combination preparations. If dietary salt intake is high, reducing it may help. If microalbuminuria or proteinuria present an ACE/ARB is required in the treatment regime unless counterindicated.

Drugs commonly used

Step	Class	Agent	Target dose range
1, 2 & 3	Angiotensin converting enzyme inhibitor (ACEI)	ramipril	10 mg
		lisinopril	20-40 mg
		perindopril	4- 8 mg
	Angiotensin receptor blocker (ARB)	irbesartan	300 mg
		losartan	100 mg
	Calcium channel blocker	amlodipine mesilate felodipine	5-10 mg 5-10 mg
	Diuretic	bendroflumethazide	2.5 mg
		indapamide SR	1.5 mg
4	Alpha blocker	doxazosin (not SR)	1-16 mg
	Beta blocker	atenolol	25-50 mg
	Aldosterone antagonist	spironolactone	12.5 – 25 mg
	Centrally acting agent	moxonidine	200 – 600 micrograms

Use an ARB only if an ACEI is not tolerated, eg. because of persistent cough. However, ARBs may have advantages over ACEIs in established diabetic nephropathy

Blood pressure lowering drug titrations

ACEIs

Ramipril:

• 2.5 mg od for 1 week
• 5 mg od for 1 week
• Check U+Es and creatinine, then if K+ normal and creatinine rise < 20%
• 10 mg od to continue
• (Consider ramipril titration pack)

Lisinopril :

• 5 mg od for 1 week
• 10 mg od for 1 week
• Check U+Es & creatinine, then if K+ normal and creatinine rise < 20% :
  • 10 mg od for 2 weeks
  • 20 mg od to continue

ARBs

• Losartan 50 mg od for 2 weeks, then if K+ normal and creatinine rise < 10% 100 mg od
• Irbesartan 150 mg od for 2 weeks, then if K+ normal and creatinine rise < 20% 300 mg od

Amlodipine and felodipine

• 5 mg od for 1 week, then 10 mg od. (Starting dose in elderly 2.5 mg od.)

Doxazosin

• 1 mg od for 1 week, 2 mg od for 1 week, 4 mg od for 1 week
• Thereafter increase dose by 2 mg every 4 weeks to maximum 16 mg od until BP controlled.

Moxonidine

• 200 mcg od for 1 week
• Then 300 mcg od for 1 week
• If necessary increase to 400 micrograms od then 300 micrograms bd.

Atenolol

• · 25 mg od increasing to 50 mg od, rarely to maximum 100 mg od.

Beta-blockers are now recommended only for resistant hypertension or when there is some other indication for their use, e.g. angina or heart failure.

Monitoring for ACEIs, ARBs and Spironolactone

• Check U+Es and creatinine at baseline, after dose increases (see drug titrations, above), and every 3-4 months thereafter.
• If creatinine rises >20% above baseline or previous recent value, discontinue the drug or reduce back to the previous dose.

These drugs should be discontinued if the serum potassium is > 5.8 mmol/l. Combinations of any two or all three of ACEI, ARB and spironolactone should be used with extreme caution because of the risk of severe hyperkalaemia.

Monitoring for diabetic nephropathy

• Check UACR and creatinine or e-GFR annually.
• If UACR suggests high risk, treatment with an ACEI or ARB is essential.
• Revise blood pressure target downwards to 125/75.
• Microalbuminuria doubles cardiovascular risk: address risk factors aggressively and commence statin therapy even if no other indication for such treatment is present.
• If there is no retinopathy, investigate for non-diabetic renal pathology.
• Consider renovascular disease, especially in patients with peripheral vascular disease.
• If e-GFR < 60, repeat and if confirmed refer to the diabetes nephrology clinic as CKD stage 3.

This work has been completed with the support of Lilly UK through an educational grant, which includes permission to use the basic IT structure and design of the website and the provision of Project Management training to the project team.