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## Complete Summary

#### GUIDELINE TITLE

The evidence base for tight blood pressure control in the management of
type 2 diabetes mellitus.

#### BIBLIOGRAPHIC SOURCE(S)

Snow V, Weiss KB, Mottur-Pilson C. The evidence base for tight blood
pressure control in the management of type 2 diabetes mellitus. Ann
Intern Med 2003 Apr 1;138(7):587-92. \[30 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12667031)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Hypertension in patients with type 2 diabetes mellitus

#### GUIDELINE CATEGORY

Management\
Risk Assessment\
Treatment

#### CLINICAL SPECIALTY

Endocrinology\
Family Practice\
Internal Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To provide clinicians with evidence-based recommendations regarding
treatment of hypertension in type 2 diabetes mellitus: setting treatment
goals, choosing optimal agents for treatment, and setting priorities in
patients with type 2 diabetes

#### TARGET POPULATION

Type 2 diabetes patients with concomitant hypertension, including
patients with some form of microvascular complications and premenopausal
women.

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Treatment/Prevention**

*Antihypertensive Drugs*

1.  Thiazide diuretics

2.  Calcium-channel blockers

3.  Beta-blockers

4.  Angiotensin-converting enzyme (ACE) inhibitors

5.  Angiotensin-II receptor blockers

6.  Alpha-blockers (should be reserved for hypertension refractory to
    other agents)

#### MAJOR OUTCOMES CONSIDERED

-   All-cause mortality

-   Cardiovascular mortality

-   Cardiovascular events (myocardial infarction, stroke, congestive
    heart failure)

-   Microvascular complications (photocoagulation, nephropathy,
    neuropathy, amputation)

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The literature review was limited to randomized, controlled trials that
included patients with diabetes. Only studies that measured major
clinical end points were included. Four classes of clinical end points
were defined: all-cause mortality, cardiovascular mortality, major
cardiovascular events (that is, myocardial infarction or stroke), and
advanced microvascular outcomes (photocoagulation or visual loss,
nephropathy or end-stage renal disease, neuropathy, or amputation). The
authors separated the literature review into two categories. The first
category evaluated the effects of hypertension control if the comparison
examined an antihypertensive drug versus placebo or the effects of
different target blood pressure levels. The second category evaluated
the effects of different classes of drugs.

Several sources were used to identify the relevant literature. For older
literature, the authors started with the Cochrane Collaboration Diabetes
Group report on treatment of hypertension in diabetes, which was
published in 1997. This report has now been withdrawn because it is out
of date, but it served as a reasonable starting point to identify
pre-1997 literature. A MEDLINE search was then performed in May 2000 and
updated in April 2002. The authors used the keywords *exp diabetes
mellitus* and *exp hypertension \[therapy or prevention and control\]*
and limited the search to randomized, controlled trials. The final
search produced 322 results. Of these, most were discarded because they
did not measure major clinical outcomes, were observational in nature,
were reviews or editorials, or did not primarily address the issue of
treatment of hypertension. The search was then updated through
consultation with experts and through examining references from
meta-analyses and review articles.

#### NUMBER OF SOURCE DOCUMENTS

322 articles

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Data were extracted from the primary study reports by the primary author
and were reviewed by the senior author. Accuracy and quality of the
abstraction were confirmed through reabstraction and comparison with the
original abstraction. The outcomes were broken into categories as
described, and data on absolute and relative risk reduction and numbers
needed to treat for benefit were derived from the primary reports or
were calculated in standard fashion.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

This paper was developed by the Clinical Efficacy Assessment
Subcommittee of the American College of Physicians (ACP). It was peer
reviewed by the American Diabetes Association, the National Diabetes
Education Program (National Heart, Lung, and Blood Institute), and the
American Academy of Family Physicians. Approved by the ACP Board of
Regents in October 2001.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Recommendation 1**: Blood pressure control must be a priority in the
management of persons with hypertension and type 2 diabetes.

**Recommendation 2**: Clinicians should aim for a target blood pressure
of no more than 135/80 mm Hg for their patients with diabetes.

**Recommendation 3**: Thiazide diuretics or angiotensin-converting
enzyme (ACE) inhibitors can be used as first-line agents for blood
pressure control in most patients with diabetes.

**Recommendation 4**: Further studies are warranted on the relative
contributions of glucose control and blood pressure control to clinical
outcomes such as microvascular and macrovascular complications.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are supported by data from randomized controlled
trials that included patients with diabetes. See related background
article: Vijan S, Hayward RA. Treatment of hypertension in type 2
diabetes mellitus: blood pressure goals, choice of agents, and setting
priorities in diabetes care. Ann Intern Med 2003 Apr 1; 138(7): 593-602.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Improved blood pressure control

-   Reduction in overall mortality

-   Reduction in cardiovascular events and microvascular complications

#### POTENTIAL HARMS

In the United Kingdom Prospective Diabetes Study (UKPDS) patients taking
beta-blockers gained more weight than those taking
angiotensin-converting enzyme (ACE) inhibitors, and beta-blocker therapy
was more frequently discontinued. In addition, patients taking
beta-blockers required the addition of new glucose-lowering agents more
frequently than those taking ACE inhibitors.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   Clinical practice guidelines are \"guides\" only and may not apply
    to all patients and all clinical situations. Thus, they are not
    intended to override clinicians\' judgment.

-   All American College of Physicians (ACP) clinical practice
    guidelines are considered automatically withdrawn or invalid 5 years
    after publication or once an update has been issued.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Patient Resources

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Snow V, Weiss KB, Mottur-Pilson C. The evidence base for tight blood
pressure control in the management of type 2 diabetes mellitus. Ann
Intern Med 2003 Apr 1;138(7):587-92. \[30 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12667031)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 Apr 1

#### GUIDELINE DEVELOPER(S)

American College of Physicians - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American College of Physicians

#### GUIDELINE COMMITTEE

Clinical Efficacy Assessment Subcommittee (CEAS)

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Authors*: Vincenza Snow, MD; Kevin B. Weiss, MD; Christel
Mottur-Pilson, PhD

*Clinical Efficacy Assessment Subcommittee Members*: Kevin Weiss, MD
(Chair); Mark Aronson, MD; Patricia Barry, MD; Nick Fitterman, MD; E.
Rodney Hornbake, MD; Keith Michl, MD; Doug Owens, MD; Allan Ronald, MD;
Katherine Sherif, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

None disclosed

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [American College of Physicians
(ACP) Web
site](http://www.annals.org/issues/v138n7/full/200304010-00017.html).

Print copies: Available from the American College of Physicians (ACP),
190 N. Independence Mall West, Philadelphia PA 19106-1572.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following background document is available:

-   Treatment of hypertension in type 2 diabetes mellitus: blood
    pressure goals, choice of agents, and setting priorities in diabetes
    care. Ann Intern Med 2003 Apr 1;138(7):593-602.

Electronic copies: Available from the [American College of Physicians
(ACP) Web
site](http://www.annals.org/issues/v138n7/full/200304010-00018.html).

Print copies: Available from the American College of Physicians (ACP),
190 N. Independence Mall West, Philadelphia PA 19106-1572.

#### PATIENT RESOURCES

The following is available:

-   Summaries for patients. Blood pressure control in people with type 2
    diabetes mellitus: recommendations from the American College of
    Physicians. Ann Intern Med 2003 Apr 1;138(7):I70.

Electronic copies: Available from the [American College of Physicians
(ACP) Web
site](http://www.annals.org/issues/v138n7/nts/200304010-00007.html).

Print copies: Available from the American College of Physicians (ACP),
190 N. Independence Mall West, Philadelphia PA 19106-1572.

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI on July 9, 2003. The information
was verified by the guideline developer on July 23, 2003.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008