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Tight blood pressure control is very important in preventing diabetic microvascular and macrovascular complications
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Ambulatory or home blood pressure monitoring may be useful if white coat hypertension suspected or possible
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Systolic BP < 130 mmHg and diastolic BP < 80 mmHg if known microvascular or macrovascular complications and/or 5 year CVD risk > 15%
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Systolic BP < 140 mmHg and diastolic BP < 90 mmHg if no microvascular or macrovascular complications and 5 year CVD risk < 5%.
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Consider systolic BP < 130 mmHg and diastolic BP < 80 mmHg if 5 year CVD risk 5-15%.
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Consider systolic BP < 125 mmHg and diastolic BP < 75 mmHg in young patients with diabetic microvascular or macrovascular complications
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Targets may need to be relaxed if hypotension problematic such as in the elderly or those with diabetic autonomic neuropathy
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Pharmacological management is dependent on presence of diabetic renal disease:
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If renal disease present– start ACE inhibitor (ACEi) or angiotensin receptor blocker (ARB). Maximise dose before addition of another agent.
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If no renal disease – Can use calcium channel blockers, thiazides or ACEi/ARBs as first and additional agents as required. ACEi/ARBs likely best first line agents if heart failure present.
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ACE inhibitors and ARBs should not be used in combination and need to ensure effective contraception in women of child bearing age.
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Review patients at least three monthly until blood pressure is to target
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Consider secondary causes of hypertension (e.g. obstructive sleep apnoea, primary hyperaldosteronism, Cushing’s syndrome, phaeochromocytoma, thyrotoxicosis etc.) if drug-resistant or if patient < 35 years of age