# Type 2 Diabetes and Hypertension

The target blood pressure (BP) is less than130/80mm. Use the steps below
to achieve this goal in patients with elevated BP.

**Step 1.** Implement Therapeutic Lifestyle Changes and begin an
angiotensin-converting enzyme (ACE inhibitor) (Lisinopril or Captopril).
If patient develops a cough or has angioedema on ACE inhibitor, use an
angiotensin II receptor blocker (ARB).

**Step 2.** If target is not reached, add a diuretic (HCTZ).

**Step 3.** If target is not reached, add either a Beta-blocker
(Metoprolol, Atenolol) or add a calcium channel blocker (Diltiazem).

**Step 4**. If target is not reached, add either Clonidine or an alpha
bocker (Doxazosin or Terazosin).

# Antihypertensive Medications

# Information on medications used to treat hypertension is listed in Tables 1 through 6 below. 

# ACE Inhibitors and ARBs are renal protective in diabetes; consider using if microalbumin is positive, even if BP is less than 130/80mm. They can cause an increase in serum potassium (K^+^) and creatinine; a cough may occur with an ACE Inhibitor but not with an ARB; and angioedema is rarely seen with an ACE Inhibitor.

# Table 1. ACE Inhibitors and ARBs 

+------------------------+---------------------------------------------+
| **Name of Medication** | **Dose Information**                        |
+------------------------+---------------------------------------------+
| Lisinopril (Prinivil, | Start 2.5 to 5mg daily; usually 20 to 40mg  |
| Zestril)              | daily                                       |
+------------------------+---------------------------------------------+
| Captopril (Capoten®)   | Start 12.5 BID-TID; max 150mg TID           |
+------------------------+---------------------------------------------+
| Losartan (Cozaar)     | Start 25 to 50mg daily; max usually 100mg   |
|                        | daily                                       |
|                        |                                             |
|                        | Consider this if patient is unable to       |
|                        | tolerate ACE Inhibitor                      |
+------------------------+---------------------------------------------+
| Telmisartan            | Start 40mg daily; usually 20 to 80mg daily  |
| (Micardis®)            |                                             |
|                        | Consider if unable to tolerate ACE          |
|                        | Inhibitor                                   |
+------------------------+---------------------------------------------+

# Table 2. Diuretics

+------------------------+---------------------------------------------+
| **Name of Medication** | ## Dose Information                         |
+------------------------+---------------------------------------------+
| HCTZ                   | ## S                                        |
|                        | tart 12.5 to 25mg daily; usually 25mg daily |
|                        |                                             |
|                        | ## Can decrease                             |
|                        |  K^+^; Problems increase with doses \> 25mg |
+------------------------+---------------------------------------------+
| **\***Maxzide®         | ## Dose                                     |
|                        | : ½ tab daily (to keep HCTZ dose at 25mg);  |
|                        |                                             |
|                        | ## 1 tab                                    |
|                        | = 50mg HCTZ/75mg triamterene; K^+^ sparing  |
|                        |                                             |
|                        | ## Use with caution especially in CKD       |
+------------------------+---------------------------------------------+

\*These drugs are not on the IHS Core Formulary

# Table 3. Beta-blockers

+---------------------+------------------------------------------------+
| **Name of           | **Dose Information**                           |
| Medication**        |                                                |
+---------------------+------------------------------------------------+
| Atenolol            | Start 25 to 50mg daily or BID; usually 50      |
| (Tenormin)         | to100mg daily                                  |
|                     |                                                |
|                     | Eliminated by renal system (use with caution   |
|                     | in Renal Failure)                              |
+---------------------+------------------------------------------------+
| Metoprolol          | Start 50 to 100mg BID; usually 100 to 450mg    |
| (Lopressor)        | daily in 1 to 2 divided doses ([XR formulation |
|                     | dosed once daily]{.underline})                 |
|                     |                                                |
|                     | Eliminated by hepatic system (use caution in   |
|                     | Liver Failure)                                 |
|                     |                                                |
|                     | Preferred β-Blocker for renal dysfunction or   |
|                     | heart failure                                  |
+---------------------+------------------------------------------------+
| \*Carvedilol (Coreg | Start 3.125 to 6.25mg; Usual dose 25mg BID     |
| ®)                  |                                                |
|                     | Consider use in patients with heart failure    |
+---------------------+------------------------------------------------+

\*These drugs are not on the IHS Core Formulary

# Do not use Beta blockers if patient has bradycardia or 2^nd^ or 3^rd^ degree block. Caution in severe CHF, asthma or renal dysfunction.

# Table 4. Calcium Channel blockers (CCA)

+-----------------------+----------------------------------------------+
| **Name of             | **Dose Information**                         |
| Medication**          |                                              |
+-----------------------+----------------------------------------------+
| Diltiazem CD          | Start 120mg daily; usually 120 to 420mg      |
| (Cardizem)           | daily                                        |
+-----------------------+----------------------------------------------+
| \*Amlodipine (Norvasc | ### Start 5mg d                              |
| ®)                    | aily; 5 to10mg daily; consider in patients w |
|                       | ith angina or congestive heart failure (CHF) |
+-----------------------+----------------------------------------------+
| # Nifedipine XL       | # Consider use if patient cann               |
|  (Adalat/ Procardia) | ot tolerate diltiazem; Start 30mg daily; usu |
|                       | ally 30 to 120mg daily; Use with caution wit |
|                       | h edema, CHF, and Myocardial Infarction (MI) |
+-----------------------+----------------------------------------------+
| Nisoldipine (Sular®)  | ### Consider use if pat                      |
|                       | ient cannot tolerate diltiazem; Start 20mg d |
|                       | aily; usually 10 to 40mg daily; NMT 60mg dai |
|                       | ly; Use with caution with edema, CHF, and MI |
+-----------------------+----------------------------------------------+

\*These drugs are not on the IHS Core Formulary

# Table 5. Alpha Blockers

  ------------------------ ----------------------------------------------
  **Name of Medication**   **Dose Information**

  **Doxazosin (Cardura)** Start 1mg immediate release at bed time (HS);
                           Max dose 16mg daily; Can cause dizziness,
                           drowsiness, and weakness; Titrate up slowly

  **Terazosin (Hytrin®)**  Start 1mg HS; Max dose 20mg daily; Can cause
                           dizziness, drowsiness and weakness; Titrate up
                           slowly
  ------------------------ ----------------------------------------------

# Table 6. General Acting 

  ------------------------ ----------------------------------------------
  **Name of Medication**   **Dose Information**

  Clonidine (Captopres®)   Start 0.mg BID; usually o.1 to o.3mg BID; Can
                           cause increase in dedation, dizziness and
                           weakness; Titrate up slowly. Do **not**
                           withdraw abruptly.
  ------------------------ ----------------------------------------------

Reference: JNC VII;
http://[www.nhlbi.nih.gov/guidelines/hypertension/index.htm](http://www.nhlbi.nih.gov/guidelines/hypertension/index.htm)