Treating hypertension in type 2 diabetes

The co-existence of diabetes and subclinical atherosclerosis in rural central Appalachia: Do residential characteristics matter?

Aim Disparities exist in cardiovascular diseases (CVD) and diabetes in the United States (U.S.) with Central Appalachia having disproportionate burden. This study examined prevalence and correlates of CVD risk-factors among patients with diabetes/subclinical atherosclerosis in Central Appalachia.

METHODS

During 2012-2016, 3000 patients from Central Appalachia were screened for subclinical atherosclerosis, using coronary artery calcium (CAC) scores; 419 participants had diabetes. Patients were categorized into four groups, with emphasis on those having subclinical atherosclerosis, CAC score ≥ 1. Descriptive statistics and multilevel multinomial logistic regression were conducted to identify CVD risk and spatial factors associated with co-existence of diabetes and subclinical atherosclerosis.

RESULTS

Among participants, prevalence of CVD risk-factors ranged from 11.7% for current smokers to 69.2% for those with CVD family history. Average BMI was 29.8. Compared to patients with diabetes only, age [RR = 1.07; p ≤ 0.0001], being male [RR = 5.33; p ≤ 0.0001], having hypertension [RR = 2.37; p ≤ 0.05] and being a former smoker were associated with increased likelihood of having diabetes/subclinical atherosclerosis. At the zip-code level, unemployment rate [RR = 1.37; p ≤ 0.05] was significantly associated with having diabetes/subclinical atherosclerosis.

CONCLUSION

Consistent with clinical guidelines, study results suggest the need to integrate CAC screening into primary care diabetes programs while addressing spatial issues that predispose patients to have diabetes/subclinical atherosclerosis.

Use of azilsartan medoxomil in the primary-care setting in Germany: A real-world evidence study

Objective: To evaluate azilsartan medoxomil (AZM) (Edarbi^®) utilization patterns in the primary-care setting in Germany. Materials and methods: This is a retrospective cohort study among patients receiving AZM in the primary-care setting in Germany. Prescription patterns – including patient demographics, off-label use, use in specific populations, concomitant use of other antihypertensive drugs, and drugs potentially causing interactions with AZM – were analyzed in two periods (01/2012 – 12/2013 and 01/2014 – 11/2016) using the primary-care physician panel of German IMS^® Disease Analyzer, a patient-level electronic medical records database. Results: In total, 852 of 1,159 (74%) and 696 of 811 (86%) patients met the inclusion criteria for both periods, respectively. Approximately 25% of patients were aged ≥ 75 years; 1 patient was < 18 years old; ~ 50% were females. AZM was prescribed for the approved indication of essential hypertension in 83% and 68% of patients in the first and second period, while indication was missing in 12% and 26% of patients, respectively. AZM was coprescribed on the same day with other antihypertensive drugs in 23% (first period) and 37% (second period) of patients. Drugs that might cause an interaction with AZM were coprescribed on the same day in 3% of patients in both periods; overlapping prescription periods were detected in 14% (first period) and 8% (second period) of patients. Coprescription of AZM with angiotensin-converting enzyme (ACE) inhibitors (2%) or aliskiren (< 1%) on the same day was rare in both periods. Overlapping prescription periods with AZM decreased from 20 to 6% for ACE inhibitors and from 8 to 1% for aliskiren. Conclusion: Findings from this real-world evidence study demonstrate that AZM was generally utilized for approved indication and in accordance with the summary of product characteristics recommendations.

Randomized trial of an increased dose of calcium channel blocker or angiotensin II type 1 receptor blocker as an add-on intensive depressor therapy in type 2 diabetes mellitus patients with uncontrolled essential hypertension: the ACADEMIE Study

There is a lack of data on how to treat hypertensive patients with diabetes when treatment with medium doses of calcium channel blocker and angiotensin II type 1 receptor blocker (ARB) is insufficient to achieve the target blood pressure (BP). A total of 121 participants with type 2 diabetes and uncontrolled essential hypertension, who were receiving medium doses of amlodipine (5 mg/day) and ARB, were enrolled. Participants were randomized to receive either a high dose of amlodipine (10 mg/day) plus a medium dose of ARB (high-AML) or a medium dose of amlodipine (5 mg/day) plus a high dose of ARB (high-ARB). The depressor effects of these two regimens were monitored using a telemonitoring home BP-measuring system. Fifty-four patients were excluded after an observation period, and the remaining 67 eligible participants were randomized into the two groups; 42 which had a record of their home BP for analysis. The change in morning home systolic and diastolic BP was greater in the high-AML than in the high-ARB (systolic BP; - 7.9 mmHg vs. + 2.7 mmHg; p = 0.0002, diastolic BP; - 3.9 mmHg vs. + 0.6 mmHg; p = 0.0007). In addition, the home systolic and diastolic BP before going to bed and office systolic BP were significantly reduced from week 0 only in the high-AML. An increased dose of amlodipine, but not ARB, reduced home morning BP in hypertensive patients with type 2 diabetes who were already receiving combination therapy with medium doses of amlodipine and ARB.

Control of Blood Pressure and Cardiovascular Outcomes in Type 2 Diabetes

High blood pressure in patients with diabetes mellitus results in a significant increase in the risk of cardiovascular events and mortality. The current evidence regarding the impact of intervention on blood pressure levels (in accordance with a specific threshold) is not particularly robust. Blood pressure control is more difficult to achieve in patients with diabetes than in non-diabetic patients, and requires using combination therapy in most patients. Different management guidelines recommend initiating pharmacological therapy with values >140/90 mm/Hg; however, an optimal cut point for this population has not been established. Based on the available evidence, it appears that blood pressure targets will probably have to be lower than <140/90mmHg, and that values approaching 130/80mmHg should be recommended. Initial treatment of hypertension in diabetes should include drug classes demonstrated to reduce cardiovascular events; i.e., angiotensin converting-enzyme inhibitors, angiotensin receptor blockers, diuretics, or dihydropyridine calcium channel blockers. The start of therapy must be individualized in accordance with the patient's baseline characteristics, and factors such as associated comorbidities, race, and age, inter alia.

Blood pressure control in type 2 diabetic patients

Diabetes mellitus (DM) and essential hypertension are common conditions that are frequently present together. Both are considered risk factors for cardiovascular disease and microvascular complications and therefore treatment of both conditions is essential. Many papers were published on blood pressure (BP) targets in diabetic patients, including several works published in the last 2 years. As a result, guidelines differ in their recommendations on BP targets in diabetic patients. The method by which to control hypertension, whether pharmacological or non-pharmacological, is also a matter of debate and has been extensively studied in the literature. In recent years, new medications were introduced for the treatment of DM, some of which also affect BP and the clinician treating hypertensive and diabetic patients should be familiar with these medications and their effect on BP. In this manuscript, we discuss the evidence supporting different BP targets in diabetics and review the various guidelines on this topic. In addition, we discuss the various options available for the treatment of hypertension in diabetics and the recommendations for a specific treatment over the other. Finally we briefly discuss the new diabetic drug classes and their influence on BP.

A Persian Adaptation of Medication Adherence Self-Efficacy Scale (MASES) in Hypertensive Patients: Psychometric Properties and Factor Structure

INTRODUCTION

Poor adherence to anti-hypertensive treatment significantly contributes to the failure to achieve well-controlled blood pressure in patients with hypertension.

AIM

To convert the original English version of Medication Adherence Self-efficacy Scale (MASES) into a Persian version for clinical application in hypertensive patients.

METHODS

The backward-forward translation method was used to produce the Persian version of the questionnaire. Then the internal consistency was assessed using Cronbach's alpha. Exploratory Factor Analysis was applied to extract the components of the questionnaire. Correlation between blood pressures and drug adherence was then determined using the Persian MASES in hypertensive patients.

RESULTS

Cronbach's alpha coefficient of the Persian version of MASES was >0.92, suggesting that it can yield consistent results. Exploratory Factor Analysis suggested an uni-dimensionality of the scale. Patients with uncontrolled hypertension showed poor adherence to hypertensive medications, therefore had significant lower self-efficacy scores than those with well-controlled blood pressure by medications.

CONCLUSION

The Persian version of MASES is valid and reliable to assess self-efficacy of antihypertensive medication adherence in hypertensive patient, which is helpful to improve medication compliance in such patients in order to achieve better blood pressure controls.