Dr. V Mohan, as part of this exclusive 12-article series on Diabetes, answers questions posted by readers on the previous article- Managing hypertension in diabetic patients.

Question 1: Which is the best anti-hypertensive drug for hypertension associated with DM?

Dr. V Mohan: The best anti-hypertensive classes of drugs for treating hypertension in those with diabetes, would be the Angiotensin Receptor Blocker drugs (ARB)s and the Angiotensin Converter Enzyme inhibitors (ACE inhibitors). While both are equally suitable, generally it is felt that for patients with type 1 diabetes the ACE inhibitors are better, while for those with type 2 diabetes the ARB drugs are better.

The reason why the ACE and ARB drugs are preferred to other agents in people with diabetes is that, apart from lowering the blood pressure, they have a direct effect on the kidney where they lower the interglomerular pressure thereby helping to reduce albuminuria and therefore help in reversal and prevention of renal disease.

Question 2: Does a patient (65 years of age) whose BP varies between 120/80 to 130/90 and is suffering from migraine need a antihypertensive?

Dr. V Mohan: For somebody who is 65 years of age with blood pressure between 120/80 to 130/90, which is almost normal and hence it may be left alone. Migraine is not due to hypertension and needs separate treatment. Having migraine is not an indication for starting an anti-hypertensive drug.

Question 3: What are safe drugs for hypertension in chronic renal failure (CRF) due to diabetes or hypertension in CRF- is it ARB or CCB or prazocin. If ARBs are being given in diabetics without CRF, should we monitor eGFR frequently?

Dr. V Mohan: In mild to moderate hypertension, the ARB group of drugs can be used. The only side effect is hyperkalaemia, so serum potassium measurements have to be done regularly. The eGFR should also be monitored. Other classes of drugs can also be used including calcium channel blockers, prazosin and other agents. In any case the eGFR should be monitored frequently and also the serum electrolytes, particularly the serum potassium.

Question 4: Please throw some light on antihypertensive recommendations for patients with different subtypes of type 2 DM.

Dr. V Mohan: There is no separate indications for using different classes of anti-hypertension drugs in different subtypes of diabetes and the recommendations for hypertension and diabetes patient will be common for all the subtypes of diabetes.

Question 5: ACE/ARB or CCB with or without diuretics what should be the right choice for blood pressure more than 180/120?

Dr. V Mohan: If the blood pressure is 180/120, clearly it is extremely high and it is very unlikely that one drug would be sufficient to lower the BP to normal limits. One can start with one drug but more likely at least two drugs, if not more, would be needed to bring the blood pressure down to minimal level.

Question 6: The ideal method to measure BP is not followed by a treating physician and cardiologists. What is your opinion about white collar BP in the consulting room and prescribing drugs?

Dr. V Mohan: While measuring the blood pressure the following conditions must be kept in mind.

1. White Coat Hypertension: This refers to a condition where the blood pressure shoots up whenever the patient comes to the clinic but it is normal when checked at home. This is usually due to anxiety, tension and the release of catecholamine and stress hormones which increase the blood pressure and heart rate. By doing home blood pressure monitoring, white coat hypertension can be diagnosed and unnecessary treatment for hypertension or escalation of anti-hypertensive drugs can be avoided.
2. Masked Hypertension: This is the opposite of white coat hypertension. When checked in the clinic the blood pressure may be normal but at home the blood pressure can be high. Again by doing blood pressure monitoring at clinic, masked hypertension can be picked up and treated.
3. Labile Hypertension: In this case, the pressure may be normal at one time of the day but may be abnormal at another time of the day or it may be normal on one day but high on another day. This can usually be diagnosed by doing Ambulatory Blood Pressure Monitoring on a couple of days which will help to identify the fluctuations in the blood pressure.
4. Dipper vs Non-Dippers: Normally the blood pressure tends to be higher in the daytime and decrease at night when one is asleep. If the night blood pressures do not dip, this is called as non-dipper and this can lead to end-organ damage. Again this can be diagnosed by doing Ambulatory Blood Pressure Monitoring. Ideally, the blood pressure must be checked in the clinic and if there was any doubt about masked hypertension or white coat hypertension or labile hypertension, it is better to do home blood pressure monitoring atleast once or twice, or still better to do an Ambulatory Blood Pressure monitoring, so that one can find out the exact status of the blood pressure.

To read articles published in the series, click,

Treatment algorithm; factors to consider while prescribing medication: Dr. V Mohan

Diabetes Q&A with Dr. V Mohan: Treatment algorithm for DM

Managing hypertension in diabetic patients: Dr. V Mohan

Is there a diet to help prevent and control diabetes?: Dr. V Mohan answers

Being a part of this exclusive series allows you to post a question for Dr. V Mohan. Answers will be pubished along with the next article in this monthly series.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author, Dr. V Mohan is the Chairman & Chief of Diabetology at Dr. Mohan’s Diabetes Specialities Centre & Madras Diabetes Research Foundation, Chennai, India.