Diabetes Mellitus: Hypertension Management

Key points

• NICE BP targets: type 2 diabetes (under 80) aim for clinic BP under 140/90 (ABPM/HBPM under 135/85); type 1 diabetes aim under 135/85, or under 130/80 if albuminuria or two or more features of metabolic syndrome. In diabetes with CKD or ACR 70 or more, aim systolic under 130 (120-129) and diastolic under 80.
• ACE inhibitors (or ARBs) are first-line antihypertensives in diabetes of any age, for their cardiorenal/renoprotective benefit.
• In people of Black African or African-Caribbean family origin with diabetes, choose an ARB in preference to an ACE inhibitor (the old 'ACEi plus CCB/diuretic first-line' rule no longer applies). Build therapy with a dihydropyridine CCB and/or a thiazide-like diuretic; add spironolactone for resistant hypertension.
• A 2013 Cochrane review: tight control (under 130/85) vs relaxed slightly reduced stroke but other outcomes were not significantly different.
• Autonomic neuropathy may worsen postural symptoms on antihypertensives; avoid routine beta-blockers in uncomplicated hypertension, especially with thiazides (insulin resistance, impaired insulin secretion, blunted autonomic response to hypoglycaemia).

Decision points in this pathway

• Patient of African or Caribbean family origin?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.