Red Flags
- BP ≥180/120 with diabetes and end-organ involvement — hypertensive emergency; immediate parenteral therapy[1]
- Albuminuria progression on optimised RAAS blockade — investigate non-diabetic glomerular disease; nephrology referral[1]
- Symptomatic orthostatic hypotension with autonomic neuropathy — modify regimen; gentle BP titration[1]
- Pregnancy with diabetes plus hypertension — stop ACE-i/ARB; switch to labetalol or methyldopa; obstetric medicine input[1]
First-line treatment
Interventions
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Telmisartan or losartan (ARB)[1] | Angiotensin receptor blocker | Telmisartan 40–80 mg PO daily; losartan 50–100 mg PO daily | — | First-line in HTN with diabetes; renal and cardiovascular protection beyond BP lowering, especially with albuminuria |
| Enalapril or ramipril (ACE-i)[1] | ACE inhibitor | Enalapril 5–40 mg PO daily; ramipril 2.5–10 mg PO daily | — | Alternative first-line; switch to ARB if dry cough develops |
| Amlodipine[1] | CCB (DHP) | 5–10 mg PO once daily | — | Combine with RAAS blockade when BP not at target |
| Indapamide or chlorthalidone[1] | Thiazide-like diuretic | Indapamide 1.5 mg sustained-release once daily | — | Third agent; preferred over hydrochlorothiazide |
| Empagliflozin or dapagliflozin[1] | SGLT2 inhibitor | Empagliflozin 10–25 mg or dapagliflozin 10 mg PO once daily | — | Modest BP reduction plus cardio-renal protection independent of glycaemic effect |
Telmisartan or losartan (ARB)[1]
Angiotensin receptor blocker
- Adult
- Telmisartan 40–80 mg PO daily; losartan 50–100 mg PO daily
- Paediatric
- —
First-line in HTN with diabetes; renal and cardiovascular protection beyond BP lowering, especially with albuminuria
Enalapril or ramipril (ACE-i)[1]
ACE inhibitor
- Adult
- Enalapril 5–40 mg PO daily; ramipril 2.5–10 mg PO daily
- Paediatric
- —
Alternative first-line; switch to ARB if dry cough develops
Amlodipine[1]
CCB (DHP)
- Adult
- 5–10 mg PO once daily
- Paediatric
- —
Combine with RAAS blockade when BP not at target
Indapamide or chlorthalidone[1]
Thiazide-like diuretic
- Adult
- Indapamide 1.5 mg sustained-release once daily
- Paediatric
- —
Third agent; preferred over hydrochlorothiazide
Empagliflozin or dapagliflozin[1]
SGLT2 inhibitor
- Adult
- Empagliflozin 10–25 mg or dapagliflozin 10 mg PO once daily
- Paediatric
- —
Modest BP reduction plus cardio-renal protection independent of glycaemic effect
Safety-net
Referral criteria
- BP ≥180/120 with end-organ involvementEmergency department for parenteral antihypertensive[1]
- Resistant hypertension uncontrolled on triple therapyHypertension or cardiology clinic[1]
- Albuminuria progression despite optimised RAAS blockadeNephrology[1]
- Pregnancy with diabetes + hypertensionObstetric medicine; stop ACE-i/ARB[1]
Clinical summary
API-ICP consensus on hypertension management in T2DM — ACE-i/ARB anchored therapy with target BP <130/80 in most patients.