LAUSR

The complications of diabetes can affect multiple organs and body systems, including the heart, brain, blood vessels, kidneys, eyes and nerves (1). Hypertension is associated with diabetes at a prevalence exceeding 70%, and it increases the probability of target organ damage and the incidence of clinical complications. Before one can begin managing hypertension in people with type 2 diabetes, it is important to know the recommended blood pressure thresholds and targets. Currently, the Diabetes Canada clinical practice guidelines and the Hypertension Canada guidelines (formerly the Canadian Hypertension Education Program) recommend a target blood pressure (BP) of <130/80 mm Hg for adults with diabetes (1,2). However, the guidelines of other countries have different targets, which leads to the following question: What is the evidence supporting this Canadian recommendation? (3). Shahi and Tobe discuss the rationale for the thresholds and targets for hypertension in adults with type 2 diabetes in this issue of the Canadian Journal of Diabetes (CJD) (4). They advocate that the current BP recommendations be maintained, based on the available scientific evidence. In this issue of CJD, Grenier et al. provide data from the Diabetes Mellitus Status in Canada (DM-SCAN) study with regard to how well primary care physicians are achieving blood pressure targets in adults with type 2 diabetes in Canada (5). The results of the DM-SCAN study have suggested that primary care physicians need to do better in achieving vascular protection targets with respect to glycated hemoglobin and cholesterol goals (6). This is especially true for BP targets as discussed by Grenier et al. Only by recognizing that this problem exists can health-care providers begin to implement strategies to achieve BP targets and, it is hoped, reduce complications. One of the major challenges of hypertension is obtaining an accurate assessment of the BP of an individual, especially if the person has diabetes. Appreciating the “true” BP is so important in guiding management. Cloutier and Lamarre-Cliche review various devices and techniques of measuring BP and consider the advantages and disadvantages of the differing techniques (7). The next challenge is selecting the appropriate medication or combination of medications to treat the hypertension, and this discussion in based on numerous trials conducted in this field of medicine, with a focus on adults with type 2 diabetes. What is the best strategy to control resistant hypertension in people with diabetes? True resistant hypertension is defined as a blood pressure level not yet at goal when a person is taking at least 3 medications from 3 different classes, including a diuretic. McFarlane reviews, in a simple structured approach, how to bring BP to target through discussion of lifestyle habits, medication adherence, interfering drugs and synergistic combinations (8). The debate between the use of angiotensin-converting enzyme inhibitors vs. angiotensin receptor blockers for blood pressure control, target organ protection and prevention of cardiovascular events in people with diabetes is still controversial. Strauss and Hall as well as Mavrakanas and Lipman have reviewed the literature and outline the pros and the cons of both classes of medications (9,10). Adherence to antihyperglycemic pharmacologic therapy in the management of type 2 diabetes is often a barrier in achieving glycemic targets. Having an open dialogue with patients about adherence and the sharing of decision-making by health-care professionals and patients are very important to delivering optimal medical care. The use of fixed-dose combination therapy for hyperglycemia has also been shown to improve adherence and, thereby, improve glycated hemoglobin results (11). Can the same principle be applied to BP targets? The most recent Hypertension Canada guidelines have advocated, in certain clinical situations, for the early use of singlepill combination therapy for hypertension management. Imbeault and Vallée discuss the evidence behind this recommendation, including the advantages, disadvantages and cost implications (12). Improvement of lifestyle behaviours remains the foundation of the prevention and treatment of diabetes and hypertension. Urrico outlines a reminder of healthful behaviours that should be covered when talking with people living with diabetes and hypertension, and the evidence that supports these synergistic interventions (13). Cardiovascular protection and BP control have been less thoroughly studied in people who have type 1 diabetes compared with people who have type 2 diabetes. BP monitoring can be a challenge in individuals with type 1 diabetes. The epidemiology, pathophysiology, risk factors and management strategies of hypertension in children with type 1 diabetes is reviewed by Downie et al. (14). In this period of rapid evolution, health-care providers will continue to aim to reduce morbidity and mortality for people living with diabetes. This issue of CJD brings much-needed attention to the importance of hypertension in this context. We should be proud of the many Canadians who have been leaders in contributing to the research and guidelines in this area of medicine. By appreciating the relationship of hypertension to diabetes, we can hope to address these 2 conditions and, ultimately, improve the care of individuals living with diabetes. We hope you enjoy this issue of CJD!