| Monitor ( see also : Organization of Clinical Monitoring
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dietary quality and quantity ( including alcohol ), physical exercise, body weight |
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sitting blood pressure ( after 5 min rest, 1st and 5th phase ) |
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Use : |
family doctor / occupational health services to obtain monthly records patient-held record card to provide cumulative record of progress
self-monitoring devices if available |
Use : |
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single agent therapy at rising doses until target achieved ( or intolerance ) |
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multiple therapy if targets not reached on maximum doses of single agents |
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once daily drug administration regimens |
Available drug classes |
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ACE-inhibitors : good evidence base in diabetes, advancing renal disease, cardiac failure |
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monitor renal function / K+ ( risk of renal artery stenosis with arterial disease ) |
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ß-Adrenergic blockers : good evidence base in diabetes and useful where angina or previous myocardial infarction |
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avoid combination with thiazides ( metabolic deterioration ), and if peripheral vascular disease. Ask about tiredness and impotence |
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ß-Adrenergic blockers : good evidence base in diabetes and useful where angina or previous myocardial infarction |
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avoid combination with thiazides ( metabolic deterioration ), and if peripheral vascular
disease. Ask about tiredness and impotence |
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Calcium channel antagonists : some evidence base in diabetes and in advancing renal disease |
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use only long-acting preparations |
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fluid retention a problem with some agents ( avoid if history of foot ulceration ) |
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Thiazides : some evidence base in diabetes |
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use low doses only and avoid combination with
ß-adrenergic blockers ( metabolic deterioration ). Ask about impotence |
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Loop diuretics : useful synergistic action with ACE-inhibitors |
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a-Adrenergic blockers : effective blood pressure lowering and metabolically beneficial |
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use only long-acting drugs ( postural hypotension ) |
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Angiotensin II receptor blockers : no special advantages |
Choise of agents - summary |
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Multiple therapy is often required; add loop diuretic to ACE-inhibitor, and avoid thiazides with
ß-adrenergic blocker; otherwise most combinations neutral |
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Many older and less expensive agents are as effective as newer agents |
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If abnormal albumin excretion, particularly if progressive, begin with ACE-inhibitor, or calcium channel antagonist if ACE-inhibitor not tolerated |
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If ischaemic heart disease, consider ß-adrenergic blocker first |
