API- ICP issue practical guidelines for doctors for management of Hypertension in patients with Type 2 Diabetes Mellitus, Details

August 1, 2024, National: Hypertension and diabetes are the top lifestyle diseases in India, responsible for the majority burden of morbidity and mortality. Over 50% of hypertensive patients also have diabetes, which is alarming. While Western guidelines exist for managing hypertension, the Indian and Southeast Asian populations differ significantly from the West in ethnicity, management challenges, and drug responses.

Keeping this in mind, the Association of Physicians of India (API) in collaboration with the Indian College of Physicians (ICP) have released the Guidelines on the Management of Hypertension in Indian Patients with Type 2 Diabetes Mellitus (T2DM). The guidelines titled "Management of Hypertension in Patients with Type 2 Diabetes Mellitus: Indian Guidelines 2024 by Association of Physicians of India (API) and Indian College of Physicians" have been published in the recent edition of JAPI.

These guidelines address in detail the factors that increase the cardio-vascular risk and the pressing need for a detailed, region-specific protocol to manage the growing dual burden of hypertension and diabetes in India.

“While global guidelines provide a framework for managing hypertension in T2DM, the Indian and Southeast Asian populations differ significantly from Western populations in terms of ethnicity, clinical challenges, and drug responses. Recognizing this gap, the API and ICP have collaborated with leading physicians, cardiologists, diabetologists, and endocrinologists to develop a management protocol specifically for Indian patients. The guidelines emphasize the importance of early detection, comprehensive assessment, and a multi-faceted treatment approach” said Dr. Jyotirmoy Pal, President-Elect (2025), API.

1) The guidelines advocate for the integration of lifestyle modifications recommending yoga as an adjunct therapy to enhance outcomes.
2) Specific emphasis is laid on using multiple methods to detect and measure hypertension, including at-home blood pressure (BP) monitoring.
3) The guidelines recommend first-line dual therapy, combining Angiotensin Receptor Blockers (ARBs) with newer Calcium Channel Blockers (CCBs) like Cilnidipine, to maximize the benefit.

Hypertension in individuals with T2DM greatly increases the risk of cardiovascular complications like heart disease, stroke, and peripheral artery disease. Assessing target organ damage and overall cardiovascular risk is essential to guide treatment intensity and preventive measures. Regular screening for microalbuminuria is recommended to identify those at risk of kidney dysfunction and future cardiovascular disease. Using specialized risk scores developed for individuals with diabetes is preferred over general population risk scores for more accurate cardiovascular risk assessment.

Given the high cardiovascular risk of T2DM, the guideline recommends a first-line treatment of dual antihypertensive therapy, specifically combining Angiotensin Receptor Blockers (ARBs) with Calcium Channel Blockers (CCBs) for their effectiveness in reducing BP and safeguarding against cardiovascular complications.

One of the major inclusions in the 2024 guidelines is the recommendation of newer CCBs, with a specific focus on Cilnidipine. Introduced in India in 2007, Cilnidipine has shown promise in offering multiple benefits, not just in reducing BP, but also in protecting crucial organs, especially the kidneys. The guidelines suggest combining Cilnidipine with ARBs to maximize these benefits, while also considering patient-specific factors and comorbidities.

Additionally, Renin-angiotensin system (RAS) blockers should be integral to the treatment regimen, given their proven efficacy in randomized controlled trials (RCTs) for preventing and slowing the progression of diabetic kidney complications. It also recommends the use of Newer anti-diabetic agents like SGLT2 inhibitors and GLP-1 receptors to improve glycemic control as well as confer macro & micro-vascular protection.

The API-ICP also recommends conditions where the patients should be further referred to specialists for better management of the disease.

One of the key features of the new guidelines is the emphasis on using multiple methods to detect and measure hypertension, including home blood pressure (BP) monitoring. This approach empowers patients to take an active role in managing their condition, improving adherence to treatment and long-term outcomes.

In addition, the guidelines advocate for the integration of lifestyle modifications to enhance treatment outcomes. For the first time, the ancient Indian practice of yoga is recommended as an adjunct therapy for managing hypertension in T2DM. Doctors are advised to recommend Yoga’s holistic benefits to patients for overall health outcomes.

Healthcare practitioners across India and beyond are encouraged to adopt these guidelines to enhance patient care and ensure the effective management of hypertension in diabetic patients. The guidelines are now available for reference in the Journal of the Association of Physicians of India (JAPI), providing a valuable resource for clinicians striving to deliver the highest standard of care.