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; avoid first-dose alpha-blockers; 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
- BP target <130/80 in diabetes[1]ADA and RSSDI recommend <130/80 mmHg in most diabetic adults; <120/80 if tolerated and high CV risk per SPRINT-extrapolation
- Lifestyle modification[1]Salt restriction <5 g/day, weight reduction if BMI ≥25, regular aerobic activity ≥150 min/week, alcohol limitation, smoking cessation
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Telmisartan or losartan[1] | Angiotensin receptor blocker (ARB) | Telmisartan 40–80 mg PO daily; losartan 50–100 mg PO daily | — | First-line in HTN with diabetes especially with albuminuria; renal and cardiovascular protection beyond BP lowering |
| Enalapril or ramipril (alternative 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] | Calcium channel blocker (DHP) | 5–10 mg PO once daily | — | Add when BP not at target on RAAS blockade alone; combines well with ARB/ACE-i |
| Indapamide or chlorthalidone[1] | Thiazide-like diuretic | Indapamide 1.5 mg sustained-release once daily; chlorthalidone 12.5–25 mg PO daily | — | Third agent when dual therapy insufficient; preferred over hydrochlorothiazide for cardiovascular outcomes |
| Spironolactone (resistant HTN in DM)[1] | Mineralocorticoid receptor antagonist | 12.5–25 mg PO once daily | — | Fourth-line per PATHWAY-2; monitor K+ closely especially with concurrent ACE-i/ARB |
| Empagliflozin or dapagliflozin (cardio-renal protection)[1] | SGLT2 inhibitor | 10 mg PO once daily (empagliflozin up to 25 mg) | — | Modest BP reduction plus cardiovascular and renal protection independent of glycaemic effect |
Telmisartan or losartan[1]
Angiotensin receptor blocker (ARB)
- Adult
- Telmisartan 40–80 mg PO daily; losartan 50–100 mg PO daily
- Paediatric
- —
First-line in HTN with diabetes especially with albuminuria; renal and cardiovascular protection beyond BP lowering
Enalapril or ramipril (alternative 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]
Calcium channel blocker (DHP)
- Adult
- 5–10 mg PO once daily
- Paediatric
- —
Add when BP not at target on RAAS blockade alone; combines well with ARB/ACE-i
Indapamide or chlorthalidone[1]
Thiazide-like diuretic
- Adult
- Indapamide 1.5 mg sustained-release once daily; chlorthalidone 12.5–25 mg PO daily
- Paediatric
- —
Third agent when dual therapy insufficient; preferred over hydrochlorothiazide for cardiovascular outcomes
Spironolactone (resistant HTN in DM)[1]
Mineralocorticoid receptor antagonist
- Adult
- 12.5–25 mg PO once daily
- Paediatric
- —
Fourth-line per PATHWAY-2; monitor K+ closely especially with concurrent ACE-i/ARB
Empagliflozin or dapagliflozin (cardio-renal protection)[1]
SGLT2 inhibitor
- Adult
- 10 mg PO once daily (empagliflozin up to 25 mg)
- Paediatric
- —
Modest BP reduction plus cardiovascular and renal protection independent of glycaemic effect
Safety-net
- Take BP and diabetes medications every day; missing doses worsens both conditions[1]
- Monitor for symptoms of low blood sugar especially when starting beta-blockers — they can mask warning signs of hypoglycaemia[1]
- Sudden severe headache, chest pain, vision changes, or weakness on one side — call emergency services immediately[1]
Referral criteria
- BP ≥180/120 with end-organ involvementEmergency department for parenteral antihypertensive[1]
- Resistant hypertension uncontrolled on triple therapyHypertension or cardiology clinic; consider secondary cause workup and renal denervation[1]
- Albuminuria progression despite optimised RAAS blockadeNephrology[1]
- Pregnancy with diabetes + hypertensionObstetric medicine; stop ACE-i/ARB[1]
Clinical summary
Blood pressure targets and pharmacotherapy in adults with diabetes and hypertension; ACE-i/ARB-anchored therapy with attention to renal and CV protection.