Rationale:

• Intensive blood pressure control can reduce the diabetic complications of retinopathy, nephropathy, and atherosclerosis.

Evidence:

• Unless otherwise contraindicated, blood pressure should be kept below 130/85 mm Hg to achieve optimal risk benefit (105).
• In a large RCT, captopril therapy was shown to decrease the risk of doubling serum creatinine by 48% and to cause a reduction in the decline of creatinine clearance (106).
• The UK Prospective Diabetes Study Group trial, a large RCT of type 2 diabetics, used captopril or atenolol to control BP aggressively in 1148 patients. In the tightly controlled group (mean BP 144/82 mm Hg) there was a decreased risk of death related to diabetes and complications, decreased progression of retinopathy, and decreased deterioration in visual acuity. Although this study was done in patients with type 2 diabetes, there is no reason not to extrapolate these implications to patients with type 1 diabetes (107).

Comments:

• Several classes of medication are available for the treatment of hypertension. ACE inhibitors may confer an additional benefit of decreasing the progression of diabetic nephropathy. Nondihydropyridine calcium-channel blockers offer an alternative to ACE inhibitors in patients who are unable to tolerate them. Patients with edema and early renal failure may require diuretic therapy.
• See module Essential Hypertension.