A 52-year-old woman is evaluated during a follow-up visit for hypertension management. She has a 10-year history of type 2 diabetes mellitus. Diabetic retinopathy was diagnosed one year ago. She also has obesity and hyperlipidemia. Medications are hydrochlorothiazide, metformin, empagliflozin, and atorvastatin.
On physical examination, blood pressure is 138/86 mm Hg; other vital signs are normal. BMI is 32. The remainder of the examination is unremarkable.
Laboratory studies show creatinine of 0.9 mg/dL (79.6 µmol/L), normal electrolytes, urine albumin-creatinine ratio of 550 mg/g, and estimated glomerular filtration rate greater than 60 mL/min/1.73 m2.
Which of the following is the most appropriate treatment?
MKSAP Answer and Critique
The correct answer is D. Losartan. This item is available to MKSAP 19 subscribers as item 37 in the Nephrology section. More information about MKSAP is online.
The most appropriate treatment is to begin losartan (Option D). Blood pressure (BP) control is more difficult to achieve in patients with diabetes mellitus, necessitating use of combination therapy in most of these patients. The 2017 American College of Cardiology/American Heart Association guideline recommends a target BP of <130/80 mm Hg for patients with hypertension and diabetes. The American Diabetes Association (ADA) recommends that most patients with diabetes and hypertension should be treated to a target BP of 140/90 mm Hg; 130/80 mm Hg may be appropriate for individuals at higher risk (existing atherosclerotic cardiovascular disease [ASCVD] or 10-year ASCVD risk ≥15%), if it can be achieved safely. In adults with diabetes and hypertension, all first-line classes of antihypertensive agents (i.e., diuretics, ACE inhibitors, angiotensin receptor blockers [ARBs], and calcium channel blockers) are useful and effective. ACE inhibitors or ARBs are the preferred drug classes for treatment of hypertension for patients with diabetes and albuminuria (albumin-creatinine ratio ≥300 mg/g) and in adults with hypertension and chronic kidney disease (stage G3 or higher or stage G1 or G2 with albuminuria) to slow kidney disease progression. Among the drug classes, ACE inhibitors and ARBs have the best efficacy on urinary albumin excretion and demonstrate a significant reduction in disease progression. The ADA also recommends use of an ACE inhibitor or ARB at the maximum tolerated dose indicated as first-line treatment for hypertension in patients with diabetes and albuminuria.
Although first-line therapy in patients with diabetes can include a thiazide diuretic or a calcium channel blocker (e.g., amlodipine) (Option A), the presence of albuminuria is an indication for the addition of a renin-angiotensin system inhibitor such as losartan.
Due to the absence of outcome data, β-blockers such as atenolol (Option B) are not usually recommended as initial antihypertensive medication therapy. However, they can be used in special populations, such as patients with a previous myocardial infarction or heart failure, in which outcome data exist.
Doxazosin (Option C) is not a typical second drug added to thiazide diuretic therapy because of its side-effect profile, which includes orthostatic hypotension. In addition, doxazosin is not as efficacious as ACE inhibitors or ARBs in preventing the progression of kidney disease.
- In adults with diabetes mellitus and hypertension, diuretics, ACE inhibitors, angiotensin receptor blockers, and calcium channel blockers are all effective agents.
- ACE inhibitors or angiotensin receptor blockers are the preferred drug classes for treatment of hypertension in patients with diabetes mellitus and albuminuria.