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Summary of Antihypertensive Agents with Emphasis on Patients with Diabetes
| Class with representative examples | Preferred use | Notable side effects | Contraindications | Effect on insulin resistance and/or glycemic control |
|---|---|---|---|---|
| ACE inhibitor* Lisinopril Ramipril Benazepril | Diabetics Also preferred in: Proteinuric CKD HFrEF Established CAD | Hyperkalemia Acute kidney injury (up to 25% rise in creatinine is expected) Angioedema Cough Teratogenicity | Pregnancy Avoid concomitant use with aliskiren or ARB | Improved |
| ARB Telmisartan Valsartan Losartan Irbesartan Candesartan | Diabetics who are intolerant of ACE inhibitors Also preferred in: Proteinuric CKD HFrEF Established CAD | Hyperkalemia Acute kidney injury (up to 25% rise in creatinine is expected) Teratogenicity | Pregnancy Avoid concomitant use with aliskiren or ACE inhibitor | Improved |
| Direct renin inhibitor** Aliskiren | Diabetics with proteinuric CKD who are intolerant of both ACE inhibitors and ARBs | Hyperkalemia Acute kidney injury Teratogenicity | Pregnancy Avoid concomitant use with ACE inhibitor or ARB | Unknown |
| Thiazide-like diuretic Chlorthalidone Indapamide HCTZ | Hypervolemic or edematous patients Must be used before diagnosing “resistant hypertension” | Photosensitivity Hyponatremia Hypokalemia Hypomagnesemia Hyperuricemia Orthostatic hypotension | Pregnancy Use with caution in cirrhotic patients (risk of hyponatremia) Ineffective in advanced CKD-GFR<30 | Worsened with HCTZ Indapamide has positive effect |
| Dihydropyridine calcium channel blocker* Nicardipine Amlodipine | Patients who are already on preferred agents but not at target blood pressure | Peripheral edema | None but should not be initiated until other preferred agents have been started | Neutral |
| Beta adrenergic blocker Carvedilol Nebivolol Metoprolol | Preferred in: History of myocardial infarction HFrEF | Orthostatic hypotension Acute decompensation of heart failure Bronchospasm Hypoglycemia unawareness Depression Impotence | Avoid in active bronchospasm, vasospastic disorders Avoid if pheochromocytoma suspected (until adequate alpha blockade) Use with caution in PVD | Worsened with non-vasodilating agents like metoprolol and not with Carvedilol and nebivolol |
| Mineralocorticoid receptor blocker Spironolactone Eplerenone Finerenone | Preferred in: HFpEF and HFrEF Resistant hypertension Primary aldosteronism | Hyperkalemia Gynecomastia (with spironolactone) | Avoid in pregnancy Caution if using with ACE, ARB or renin inhibitors | Improved with spironolactone, unknown with other agents |
Preferred agents within each class are bolded. Preference is based on available evidence from randomized control trials.
All agents in this class are considered equivalent
Only agent currently approved in this class
Abbreviations: ACE: Angiotensin converting enzyme; ARB: Angiotensin receptor blocker; CAD: Coronary artery disease; CKD: Chronic kidney disease; HCTZ: Hydrochlorothiazide; HFpEF: Heart failure with preserved ejection fraction; HFrEF: Heart failure with reduced ejection fraction; PVD: Peripheral vascular disease. GFR: Glomerular Filtration rate
From: Hypertension in Diabetes
This electronic version has been made freely available under a Creative Commons (CC-BY-NC-ND) license. A copy of the license can be viewed at http://creativecommons.org/licenses/by-nc-nd/2.0/.
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