Figure 1.

Algorithm for treatment of hypertension in inividuals with diabetes. Maximize dose before starting the next drug.

First line = ACEi or ARB (equivalence seen in DETAIL73 ONTARGET75 and VALIANT76).

• Both reduce microalbuminuria and rate of nephropathy independently of their antihypertensive effect.
• ACEi preferred over ARB (indirect evidence for cardiovascular outcomes; SCOPE,70 VALUE71 and TRANSCEND72).
• Recommend against concomitant use of ARB with ACEi (ONTARGET75 and VALIANT76).

Second line = CCB or diuretic

• Dihydropyridine CCB favored over diuretic (ACCOMPLISH82 and GUARD83) or in the presence of electrolyte anomalies.
• Diuretic preferred in heart failure or edematous conditions.
• Loop diuretic recommended if GFR ≤ 30 mL/min due to marked state of fluid overload.
• If needed, CCB and diuretic can be combined.

Third line = β-blocker, primarily due to side effect profile. However, it is indicated in all patients with established CAD and MI.

Fourth line = Aldosterone antagonist (ASCOT-BPLA86).

Fifth line = Renin inhibitor or α-blocker, not enough comparative data from clinical trials for clear recommendation.

Peripheral α-blocker, due to orthostatic hypotension and results of ALLHAT.78 It could be used earlier in patients with symptomatic BPH.

^arenal artery stenosis, hyperaldosteronism, Cushing’s syndrome or pheochromocytoma.

Abbreviations: BP, blood pressure; ACEi, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker; CCB, calcium channel blocker; CAD, coronary artery disease; MI, myocardial infarction; HTN, hypertension; GFR, glomerular filtration rate; BPH, benign prostate hyperplasia.