Clinical features and therapeutic perspectives on hypertension in diabetics

Over 50% of patients with diabetes mellitus, either type 1 or 2, ultimately develop hypertension as a complication. In diabetics, this further increases the incidence of cardiovascular disease (CVD) by 2- to 3-fold and accelerates the progression of diabetic nephropathy. Arteriosclerosis, a clinical feature of hypertension in diabetics, develops and advances from a young age. Therefore, in providing treatment, it is necessary to evaluate the degree of arteriosclerosis. Diabetic patients are encouraged to strictly control their blood glucose levels. Recently developed drugs, such as GLP-1 receptor agonists, DPP-4 inhibitors and SGLT2 inhibitors, also have hypotensive actions, making them ideal for use in diabetics with hypertension. SGLT2 inhibitors and GLP-1 receptor agonists reportedly suppress the onset and progression of CVD, as well as diabetic nephropathy. The possibility of hypoglycemia triggering blood pressure elevation and arrhythmia has been noted, so a key point here is not to cause hypoglycemia. In selecting hypotensive agents, we must choose types that do not aggravate insulin resistance and engage in hypotensive treatment that also considers both nocturnal and morning hypertension. In addition, facing the onset of an aging society, there is a growing need for treatments that do not cause excessive blood pressure reduction or hypoglycemia. Favorable lifelong blood pressure and glucose control are increasingly important for the treatment of diabetes accompanied by hypertension.

Blood pressure-lowering effect and duration of action of bedtime administration of doxazosin determined by home blood pressure measurement

The effects and duration of action of bedtime administration of doxazosin 2 mg for 4 weeks on uncontrolled morning home hypertension were investigated. Morning home blood pressure (HBP) was significantly lowered by bedtime administration of doxazosin. Doxazosin significantly lowered evening HBP only in the subgroup of patients with an uncontrolled evening HBP. The evening (E)/morning (M) ratio was greater in patients with an uncontrolled evening HBP than in those with a controlled evening HBP. The results suggest that bedtime administration of doxazosin effectively suppresses morning HBP in uncontrolled morning hypertensives and lowers evening HBP in uncontrolled evening hypertensives.

Uncontrolled hypertension based on morning and evening home blood pressure measurements from the J-HOME study

We evaluated the control condition of morning and evening home blood pressure (BP) and compared patients who had isolated uncontrolled morning hypertension and those who had sustained uncontrolled (morning and evening) hypertension using data from the Japan Home versus Office Blood Pressure Measurement Evaluation study. We evaluated 3303 treated hypertensive patients (mean age, 66.2+/-10.5 years; men, 44.7%) in Japan. We classified patients into controlled hypertension, isolated uncontrolled evening hypertension, isolated uncontrolled morning hypertension and sustained uncontrolled hypertension, based on the cutoff value of 135/85 mm Hg for both morning and evening home BP. Of the 3303 patients evaluated, 24.6% had isolated uncontrolled morning hypertension, and 42.0% had sustained uncontrolled hypertension. Factors associated with isolated uncontrolled morning hypertension included taking evening BP measurement after drinking alcohol or bathing. Factors associated with sustained uncontrolled hypertension were male gender, diabetes mellitus and renal disease. The regimen of antihypertensive medication was more complex in patients with uncontrolled morning hypertension than in controlled hypertension. Determinants of the difference between patients with isolated uncontrolled morning hypertension and those with sustained uncontrolled hypertension were diabetes mellitus, renal disease and lower prevalence in measuring evening BP after drinking alcohol or bathing. More than a half of the treated patients were classified into uncontrolled morning hypertension, which were associated with poorer prognosis. Classification of morning hypertensive patients into groups with or without evening hypertension may be useful for evaluating patients' total cardiovascular disease risk. Physicians should also consider evening BP measuring condition for adequate evaluation of evening BP values.

Effect of the 2004 Mid-Niigata Prefecture Earthquake on Home Blood Pressure Measurement in the Morning in Type 2 Diabetic Patients

A major earthquake struck the Niigata Prefecture, Japan, on October 23, 2004. This study investigated the effect of the earthquake on morning home blood pressure (MHBP) measurements, as well as clinic blood pressure (CBP) and associated complications, in 222 type 2 diabetic patients who measured MHBP and CBP before the earthquake. Physical and laboratory examinations were assessed at every three months. Each patient completed a questionnaire on MHBP measurement, Japanese intensity grade (JIS), patient's lifestyle and psychological impact using posttraumatic stress disorder (PTSD) symptom score. Median JIS showed all patients lived in areas affected by strong aftershocks. Most patients stayed in their own houses, while one-third of patients sought refuge in other houses. No new clinical manifestations of disease were noted. Median PTSD score was low. Patients in public refuge houses had daytime blood pressure, but MHBP was not measured. In the first month, the number of patients who continued MHBP measurements decreased to 27% of pre-shock level. Many patients were unable to measure MHBP for several reasons, including losing MHBP equipment, having equipment destroyed, or suffering from anxiety due to the extensive devastation. Mean systolic MHBP and median urinary albumin excretion rate (UAER) increased significantly within three months and returned to pre-earthquake level at six months. On multiple regression analysis, increased systolic and diastolic MHBPs were significantly associated with UAER elevation. In type 2 diabetic patients following an earthquake, it is important to develop a device of MHBP measurement for maintaining control of MHBP to prevent vascular complications.

Changes in home versus clinic blood pressure with antihypertensive treatments: a meta-analysis

Home blood pressure (HBP) monitoring is recommended for assessing the effects of antihypertensive treatment, but it is not clear how the treatment-induced changes in HBP compare with the changes in clinic blood pressure (CBP). We searched PubMed using the terms "home or self-measured blood pressure," and selected articles in which the changes in CBP and HBP (using the upper arm oscillometric method) induced by antihypertensive drugs were presented. We performed a systematic review of 30 articles published before March 2008 that included a total of 6794 subjects. As there was significant heterogeneity in most of the outcomes, a random effects model was used for the meta-analyses. The mean changes (+/-SE) in CBP and HBP (systolic/diastolic) were -15.2+/-0.03/-10.3+/-0.03 mm Hg and -12.2+/-0.04/-8.0+/-0.04 mm Hg respectively, although there were wide varieties of differences in the reduction between HBP and CBP. The reductions in CBP were correlated with those of HBP (systolic BP; r=0.66, B=0.48, diastolic BP; r=0.71, B=0.52, P<0.001). In 7 studies that also included 24-hour BP monitoring, the reduction of HBP was greater than that of 24-hour BP in systolic (HBP; -12.6+/-0.06 mm Hg, 24-hour BP; -11.9+/-0.04 mm Hg, P<0.001). In 5 studies that included daytime and nighttime systolic BP separately, HBP decreased 15% more than daytime ambulatory BP and 30% more than nighttime ambulatory BP. In conclusion, HBP falls approximately 20% less than CBP with antihypertensive treatments. Daytime systolic BP falls 15% less and nighttime systolic BP falls 30% less than home systolic BP.

Optimal timing for antihypertensive dosing: focus on valsartan

Some specific features of the 24 h blood pressure (BP) pattern are linked to the progressive injury of target tissues and the triggering of cardiac and cerebrovascular events. In particular, many studies show the extent of the nocturnal BP decline relative to the diurnal BP mean (the diurnal/nocturnal ratio, an index of BP dipping) is deterministic of cardiovascular injury and risk. Normalization of the circadian BP pattern is considered to be an important clinical goal of pharmacotherapy because it may slow the advance of renal injury and avert end-stage renal failure. The chronotherapy of hypertension takes into account the epidemiology of the BP pattern, plus potential administration-time determinants of the pharmacokinetics and dynamics of antihypertensive medications, as a means of enhancing beneficial outcomes and/or attenuating or averting adverse effects. Thus, bedtime dosing with nifedipine gastrointestinal therapeutic system (GITS) is more effective than morning dosing, while also reducing significantly secondary effects. The dose-response curve, therapeutic coverage, and efficacy of doxazosin GITS are all markedly dependent on the circadian time of drug administration. Moreover, valsartan administration at bedtime as opposed to upon wakening results in improved diurnal/nocturnal ratio, a significant increase in the percentage of patients with controlled BP after treatment, and significant reductions in urinary albumin excretion and plasma fibrinogen. Chronotherapy provides a means of individualizing treatment of hypertension according to the circadian BP profile of each patient, and constitutes a new option to optimize BP control and reduce risk.

Beneficial Effect of Cilnidipine on Morning Hypertension and White-Coat Effect in Patients with Essential Hypertension

Home blood pressure has a higher predictive power for cardiovascular events than office blood pressure, and there is a particularly close association between morning blood pressure at home and the incidence of cardiovascular events and mortality in the early morning. In this study, we evaluated the efficacy of a long-acting N-type and L-type calcium channel blocker, cilnidipine, in reducing morning blood pressure at home and in ameliorating the white-coat effect. Fifty-eight subjects diagnosed with both essential hypertension and morning hypertension (43 currently being treated, 15 new patients) were prescribed cilnidipine at a dosage of 10-20 mg per day for 8 weeks. After the addition of or a change to cilnidipine, the morning systolic blood pressure (SBP) was controlled to less than 135 mmHg in 25 (58%) out of the 43 patients currently receiving antihypertensive medication. The office SBP in 24 out of those 25 patients was also maintained under 140 mmHg. In the 15 newly treated patients, the morning SBP of 12 patients (80%) was controlled to less than 135 mmHg after administration of cilnidipine. At baseline, 17 patients showed a clear white-coat effect, in which the difference between office blood pressure and home blood pressure was 20/10 mmHg or more. The white-coat effect was depressed significantly after cilnidipine administration. These results suggest that cilnidipine may serve as a useful antihypertensive medication in the treatment of morning hypertension, and also attenuate the white-coat effect in patients with essential hypertension.