Second Leg of the Healthy Heart Project, Khan Sahib, Distt Budgam | Managing Patients with Diabetes and High BP “Deadly Duo"

One of the goals of Gauri Healthy Heart Project (GHHP) is to identify the deficiencies in the treatment of high blood pressure (HBP) and diabetes mellitus (DM) in various districts of J&K. In Kupwara we found that of the diabetics on treatment 80 percent had high BP also.

Towards the same aim our second district visit on 31st of October is Community Medical Centre at Krimshore, Khan sahib, District Budgam. One of our focusses will be to study the patients having coexisting DM and HBP.

The co-existence of high BP and DM is a common phenomenon.   As per scientific reports up to 80% people with DM have BP higher than 140/90 mms Hg. HBP in a diabetic predisposes to heart attacks, stroke, and CKD. This combination is therefore also named a “Deadly Duo”. An estimated 6.5 million patients in India and 1.3 million in J&K have it.

DM is very often accompanied with high levels of bad cholesterol and triglycerides which adds to the problem. This leads to blood vessel damage, stroke, heart attacks, failure and CKD especially with uncontrolled BP. We found high lipid levels in > 70 % diabetic patients in the Kupwara experience.

What should be the ideal target of BP in Diabetics?

The first objective should be to lower BP to <140/80 mmHg, aiming at a systolic blood pressure (SBP) of 130 mmHg. If the treatment is well tolerated, the SBP values of <130 mmHg should be considered for further benefit. SBP values of <120 mmHg should be avoided. The target in patients who have additional CKD has been debatable. The consensus now is that BP in this situation also should be lowered to <140/80 mmHg and aiming at 130/80 mmHg.

Lifestyle advice, especially salt restriction, may be especially effective at aiding BP lowering in patients with associated CKD. Because BP lowering reduces blood flow to kidneys, it is not unusual for serum creatinine to increase by 10 − 20% in these patients of HBP.  Thus, careful monitoring of blood electrolytes and serum creatinine is essential and there should be no alarm by an initial increase in serum creatinine, when treatment is initiated. This increase usually occurs in the beginning but stabilizes most often thereafter. If this increase becomes more severe, it needs to be brought to the attention of the treating physician and the treatment strategy may have to be changed.

How should HBP be treated in a diabetic?

Most patients with DM and high BP need drug treatment. The choice of agent to be used is important because it is not only important to bring down the BP to target < 140/80 mms Hg but also to protect kidneys and heart to get involved because of this dual problem.

ACEI (angiotensin converting enzyme inhibitors) and ARB’s (angiotensin II receptor blockers) are the group of medications that are often used to treat high blood pressure for people with diabetes. Although other HBP medicines are available, ACEI and ARB’s treat HBP effectively and also prevent or slow the onset of heart and kidney disease in people with DM. Examples of these medicines are enalapril, ramipril, perindopril etc (ACEI), losartan, telmisartan, olmesartan (ARB’s) etc. These are taken under medical supervision.

It is always good to start with a combination of 2 drugs like ACEI/ARB’s with Calcium channel blockers (CCB’s) like amlodipine, cilnidipine or benidipine etc. A third agent like a diuretic or a beta blocker needs to started if BP is still above the target. The choice of drugs should be left to the treating doctor. ACEI and ARB’s are never combined together.

Cost of the agents and their combinations should always be an important consideration since the treatment is long term and often lifelong.

Importance of life style measures in these patients

It is a very important adjunct in these patients even if multiple drugs are required. These measures can reduce the number of drugs needed and also postpone start of drugs with BP close to 140 /90 mms Hg. The measures include: total cessation of smoking, reducing salt intake to minimum, consuming fresh fruits and vegetables several time a day, regular exercise for more than 30 minutes a day, and marked limitation of alcohol use.

How to control DM effectively to improve survival and prevent hospitalization?

The first goal is to keep the glycosylated Hb < 7 %, however how it is controlled also matters.

The research in the last five years has brought in new group of drugs to improve the event free survival markedly. These are over and above common drugs like metformin, gliclazide, sitagliptin, linagliptin and also insulin etc. These drugs belong to 2 groups which besides glucose lowering have remarkable properties of improving the survival, reducing vascular events and repeated hospitalizations. They do not produce hypoglycaemia and reduce body weight also by several mechanisms.

Sodium glucose co-transfer 2 (SGLT2) inhibitors also called “Gliflozins”.

These agents act by actively removing glucose from body through urine along with water and thereby reduce blood sugar significantly. They also in effect reduce BP, body weight and prevent heart failure which is a common problem in DM and thereby improve survival and reduce hospitalizations. A number of agents are available and approved: canagliflozin, dapagliflozin and empagliflozin. One of these should be used in all patients wherever possible with or without other commonly used drugs. Some patients with urinary or genital infections need to be very careful regarding their use. These agents dapagliflozin and empagliflozin have also been shown to be useful in treating patients with heart failure with low heart function (Reduced Ejection Fraction) by improving survival

Glucagon-like peptide-1 analogues (GLP1 analogues)

This group of drugs has revolutionised the management of DM in those, who are prone to vascular events like heart attacks, strokes and CKD. These agents are liraglutide, dulaglutide, exenatide and lixisenatide. They act by reducing inflammation, stabilization and reducing the fat deposition in the artery. These are indicated in diabetics who have already have had a heart attack, a brain stroke or CKD.

Studies with these agents have shown 15 to 20 % reduction in cardio vascular and 10-15% reduction in all cause deaths. These agents in addition reduce the body weight significantly which is a great advantage in obese diabetics.

The disadvantage of these drugs of being only injectable agents has also been overcome recently. Semaglutide a new GLP1 analogue is once a day oral preparation, and going to be available in India.

Essential adjuncts:

All subjects with DM in association with or without high BP need statin group of drugs in high doses to keep the bad cholesterol levels very low. These drugs: atorvastatin and rosuvastatin are often not being prescribed or used in a low dose. Lower the levels of LDL c kept the better it is for vasculo-protection.  Levels below 55 mgs/dl are advocated. Triglyceride elevation usually because of a poor sugar control. Additional hypo-thyroidism should be looked for and treated. Triglyceride lowering medicines are of unproven benefit and need to be avoided unless levels are more than 300 to 400 despite statins.

What about aspirin?

Aspirin in small dose (75 to 100 mgs/day) is only needed if the person has had a previous heart attack, a stroke, a procedure like angioplasty with stent or bypass surgery. Otherwise it has no beneficial role and can cause dangerous bleeds.

Take home message:

Majority of patients with DM have associated high BP. Both problems need aggressive management. Life style changes, use of heart and kidney protective drugs (ACEI’s or ARB’s) in combinations with CCB’s are essential. Always treat BP to a target of below 140/80 mms Hg, preferably up to 130 systolic but not below 120mms Hg. DM control is important and a goal of HbA1c of 7 or below is sought. Use of agents like SGLT2 inhibitors (Gliflozins) and GLP1 analogues (glutides etc) should be promoted in high risk groups. High dose Statins are a must and aspirin only for those who have had a previous vascular event and is not meant for all.

Author is a Cardiologist, Past President of Cardiological Society of India. Recipient of Dr B C Roy Award and Padma Shri. Founder Director Gauri Healthy Heart Project.