Tratamiento de la hipertensión arterial en la diabetes mellitus tipo 2

Article information

La hipertensión arterial es una complicación con una prevalencia en la diabetes mellitus tipo 2 muy alta, y supone un factor de riesgo para el desarrollo de complicaciones cardiovasculares. El control estricto de la presión arterial hasta cifras menores de 130/80 mmHg reduce la morbimortalidad cardiovascular y renal en mayor grado que el control del resto de las complicaciones. Para conseguir este nivel se requieren, al menos, 2 o 3 fármacos en la mayoría de los pacientes. El tratamiento de la hipertensión arterial en el diabético se basa en la realización de medidas higienicodietéticas o cambios en el estilo de vida, tratamiento farmacológico y control del resto de los factores de riesgo cardiovascular. Para el tratamiento farmacológico, los fármacos de elección son los bloqueadores del sistema renina-angiotensina-aldosterona (inhibidores de la enzima conversiva de la angiotensina y antagonistas de los receptores de la angiotensina II). En el siguiente escalón terapéutico se sitúan los diuréticos y antagonistas del calcio. Otros fármacos que se pueden utilizar son los bloqueadores beta, los bloqueadores alfa y los agentes de acción central. El conocimiento de la fisiopatología de la hipertensión arterial en la diabetes mellitus tipo 2, así como los distintos fármacos que utilizar, es importante para un tratamiento óptimo de esta frecuente complicación, con claros beneficios en la morbimortalidad de los diabéticos.

Palabras clave:

Hipertensión arterial

Diabetes mellitus

Objetivos

Hiperpotasemia

Deterioro renal

Hypertension is a highly prevalent complication in patients with type 2 diabetes mellitus and is a major risk factor for the development of cardiovascular disease. Reducing blood pressure to less than 130/80 mm Hg decreases cardiovascular and renal morbidity and mortality more than control of other associated complications. To obtain this blood pressure level, most patients need no less than 2 or 3 antihypertensive drugs. Treatment of hypertension in diabetic patients includes lifestyle changes, as well as antihypertensive agents and control of other potential cardiovascular and renal risk factors. The first line pharmacologic treatment of hypertension includes angiotensin converting enzyme inhibitors and/or angiotensin II receptor blockers. The second step includes diuretics and calcium channel blockers. Other useful drugs are betablockers, alpha-blockers and central alphaagonists. Knowledge of the physiopathology of hypertension in type 2 diabetic patients, and of the mechanisms of action of the different antihypertensive drugs allows appropriate treatment of this frequent complication in diabetic patients, with well established beneficial effects on morbidity and mortality.

Key words:

High blood pressure

Diabetes mellitus

Goals

Hyperkaliemia

Kidney failure

Full text is only aviable in PDF

Bibliografía

[1.]

J.R. Sowers, M. Epstein, E.D. Frohlich.

Diabetes, hypertension and cardiovascular disease.

Hypertension, 37 (2001), pp. 1053-1059

Medline

[2.]

L. Tarnow.

Prevalence of arterial hypertension in diabetic patients before and after the JNC-V.

Diabetes Care, 17 (1994), pp. 1247-1251

Medline

[3.]

O. García Vallejo, J.V. Lozano, O. Vegazo, F.J. Jiménez Jiménez, J.L. Llisterricaro, J. Redon.

Control de la presión arterial en pacientes diabéticos en atención primaria. Estudio DIAPA.

Med Clin (Barc), 120 (2003), pp. 529-534

[4.]

Management of hypertension in diabetes and chronic kidney disease In National Kidney Foundation: K/DOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease. Am J Kidney Dis. 2007; 49 Suppl 2:S74-S87.

[5.]

R.D. Harris, M.W. Steffes, R.W. Bilous, D.E. Sutherland, S.M. Mauer.

Global glomerular sclerosis and glomerular arteriolar hyalinosis in insulin dependent diabetes.

Kidney Int, 40 (1991), pp. 107-114

Medline

[6.]

M. Epstein, J.R. Sowers.

Diabetes mellitus and hipertensión.

Hypertension, 19 (1992), pp. 403-418

Medline

[7.]

S.H. Saydah, J. Fradkin, C.C. Cowie.

Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes.

JAMA, 291 (2004), pp. 335-342

http://dx.doi.org/10.1001/jama.291.3.335 | Medline

[8.]

UK Prospective Diabetes Study Group.

Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes: UKPDS 36.

BMJ, 321 (2000), pp. 412-419

Medline

[9.]

R.W. Schrier, R. Estacio, B. Jeffers.

Appropriate blood pressure control in NIDM (ABCD) trial.

Diabetologia, 39 (1996), pp. 1646-1654

[10.]

L. Hansson, A. Zanchetti, S.G. Carruthers, B. Dahlöf, D. Elmfeldt, S. Julius, For the HOT Study Group, et al.

Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial.

Lancet, 351 (1998), pp. 1755-1762

Medline

[11.]

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). JAMA. 2003;289:2560-72.

[12.]

Guidelines Committee.

2003 European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension.

J Hypertens, 21 (2003), pp. 1011-1053

http://dx.doi.org/10.1097/01.hjh.0000059051.65882.32 | Medline

[13.]

American Diabetes Association.

Standards of Medical Care in Diabetes-2006.

Diabetes Care, 29 (2006), pp. S4-S42

Medline

[14.]

R. Marin, A. de la Sierra, P. Armario, C. Campo, J.R. Banegas, M. Gorostidi.

En representación de la Sociedad Española de Hipertensión-Liga Española para la Lucha contra la Hipertensión Arterial (SEH-LELHA) Guía sobre el diagnóstico y tratamiento de la hipertensión arterial en España 2005.

Med Clin (Barc), 125 (2005), pp. 24-34

[15.]

C.E. Mogensen.

Combined high blood pressure and glucose in type 2 diabetes: double jeopardy. British trial shows clear effects of treatment, especially blood pressure reduction.

BMJ, 317 (1998), pp. 693-694

Medline

[16.]

E. Grossman, F.H. Messerli, H. Goldbourt.

High blood pressure and diabetes mellitus. Are all antihypertensive drugs created equal?.

Arch Intern Med, 160 (2000), pp. 2447-2452

Medline

[17.]

C.M. Dezii.

A retrospective study of persistence with single-pill combination therapy vs. concurrent two-pill therapy in patients with hypertension.

Manag Care, 9 (2000), pp. 2-6

Medline

[18.]

P. Ruggenenti, A. Fassi, A.P. Ilieva, For the Bergamo Nephrologic Diabetes Complications Trial (BENEDICT) Investigators, et al.

Preventing Microalbuminuria in Type 2 Diabetes.

N Engl J Med, 351 (2004), pp. 1941-1951

http://dx.doi.org/10.1056/NEJMoa042167 | Medline

[19.]

Heart Outcomes prevention Evaluation (HOPE) Study Investigators.

Effects of ramipril on cardiovascular outcome on people with diabetes mellitus: results in the HOPE study and micro-HOPE study.

Lancet, 355 (2000), pp. 253-259

Medline

[20.]

H.H. Parving, H. Lehnert, J. Bröchner-Mortensen, R. Gomis, S. Andersen, P. Arner, On behalf of Irbesartan in Patients with Type 2 Diabetes and Microalbuminuria Study Group.

For the Irbesartan in patients with type 2 diabetes and microalbuminuria study group.

N Engl J Med, 345 (2001), pp. 870-878

[21.]

G. Viberti, N.M. Wheeldon, For the MicroAlbuminuria reduction with Valsartan (MARVAL) Study investigators.

Microalbuminuria reduction with valsartan in patients with type 2 diabetes mellitus: a blood pressure-independent effect.

Circulation, 106 (2002), pp. 672-678

[22.]

A.H. Barnett, S.C. Bain, P. Bouter, For the Diabetics Exposed to Telmisartan and Enalapril Study Group, et al.

Angiotensin-receptor blockade versus converting-enzime inhibition in type 2 diabetes and nephropathy.

N Engl J Med, 351 (2004), pp. 1952-1961

http://dx.doi.org/10.1056/NEJMoa042274 | Medline

[23.]

E.J. Lewis, L.G. Hunsicker, W.R. Clarke, et al.

Renoprotective effects of angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes.

N Engl J Med, 345 (2001), pp. 851-860

http://dx.doi.org/10.1056/NEJMoa011303 | Medline

[24.]

B.M. Brenner, M.E. Cooper, D. De Zeeuw, W.F. Keane, W.E. Mitch, H.H. Parving, et al.

Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. RENAAL study investigators.

N Engl J Med, 345 (2001), pp. 861-869

http://dx.doi.org/10.1056/NEJMoa011161 | Medline

[25.]

W.F. Keane, B.M. Brenner, D. De Zeeuw, J.P. Grunfeld.

The risk of developing end-stage renal disease in patients with type 2 diabetes and nephropathy: the RENAAL Study.

Kidney Int, 63 (2003), pp. 1499

http://dx.doi.org/10.1046/j.1523-1755.2003.00885.x | Medline

[26.]

J.D. Curb, S.L. Pressel, J.A. Cutler, P.J. Savage, W.B. Applegate, H. Black, et al.

Effect of diuretic-based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with isolated systolic hypertension. Systolic Hypertension in the Elderly Program Cooperative Research Group.

JAMA, 276 (1996), pp. 1886-1892

Medline

[27.]

G. Bakris, M. Molitch, A. Hewkin, M. Kipnes, P. Sarafidis, K. Fakouhi, On behalf of the STAR Investigators.

Differences in Glucose Tolerance Between Fixed-Dose Antihypertensive Drug Combinations in People With Metabolic Síndrome.

Diabetes Care, 29 (2006), pp. 2591-2597

[28.]

W.C. Cushman, C.E. Ford, J.A. Cutler, et al.

Success and predictors of blood pressure control in diverse North American settings: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack trial (ALLHAT).

J Clin Hypertens (Greenwich), 4 (2002), pp. 393-405

[29.]

R. Pedrinelli, G. Dell’Omo, M. Mariani, et al.

Calcium channel blockers, postural vasoconstriction and dependent oedema in essential hypertension.

J Hum Hypertens, 15 (2001), pp. 455-461

http://dx.doi.org/10.1038/sj.jhh.1001201 | Medline

[30.]

L.H. Lindholm, H. Ibsen, B. Dahlof, et al.

Cardiovascular morbidity and mortality in patients with diabetes in the losartan intervention for endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol.

Lancet, 359 (2002), pp. 1004-1010

http://dx.doi.org/10.1016/S0140-6736(02)08090-X | Medline

[31.]

E.J. Lewis, L.G. Hunsicker, R.P. Bain, R.D. Rohde.

The effect of angiotensin- converting-enzyme inhibition on diabetic nephropathy The Collaborative Study Group.

N Engl J Med, 329 (1993), pp. 1456-1462

http://dx.doi.org/10.1056/NEJM199311113292004 | Medline

[32.]

D.J. Lush, J.A. King, J.C. Fray.

Pathophysiology of low renin syndromes: Sites of renal secretory impairment and prorenin overexpression.

Kidney Int, 43 (1993), pp. 983-990

Medline