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Q: How should you modify SW’s antihypertensive regimen at this time?
A: Most patients with hypertension—whether or not they have diabetes—will require a combination of 2 or more drugs to achieve target blood pressure goals. Addition of a second drug from a different class should be initiated when use of a single drug in adequate doses fails to achieve the blood pressure goal. Changing blood pressure medications at this time is unlikely to show any benefit and another agent should be added at this time. A third agent should be added if a combination of two drugs from different classes does not achieve SW’s blood pressure goal.
The JNC-7 guidelines recommend thiazide diuretics, beta blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and calcium channel blockers (CCBs) for patients with diabetes because they have been shown to reduce CVD and stroke incidence in patients with diabetes (see Figure 1; Table 4). ACE inhibitors and ARBs have favorable effects on the progression of diabetic nephropathy and reduce albuminuria, and ARBs have been shown to reduce progression to macroalbuminuria. Unfortunately, nearly 75% of patients with diabetes who take antihypertensive medications are not at target goals.11
Metoprolol, a beta blocker, is added to the antihypertensive regimen and is titrated to 50 mg twice daily. After an unsuccessful trial of diet therapy for 1 month, SW is started on rosiglitazone 2 mg/metformin 500 mg (1 tablet daily). Combination therapy with metformin and a thiazolidinedione offers the additional benefit of complementary mechanisms of action to preserve beta cell function and improve insulin sensitivity from the onset of therapy.12
After another month, his fasting blood glucose is 130 mg/dL and his blood pressure is 140/86 mm Hg. His triglycerides have dropped to 180 mg/dL. Amlodipine 5 mg is added to his antihypertensive regimen and his rosiglitazone/metformin dose is increased to 2 tablets twice a day (2 mg/500 mg).
His results after 3 months of combination therapy are seen in Table 5. His weight has stabilized and he is planning to start an exercise program and to join Weight Watchers.
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