Antihypertensive treatment

Although many intervention trials have been conducted using different anti-hypertensive agents in diabetic and non-diabetic subjects, few studies have been conducted exclusively in obese subjects, and some studies have specifically excluded very obese patients. The average body mass index (BMI) in the UKPDS study was approximately 29kg/m2, but no sub-group analysis based on BMI has been reported. There is clear evidence from the literature that obese hypertensive patients have higher circulating catecholamine concentrations and greater activity of the renin-angiotensin system than non-obese patients, but it is unknown whether this is also the case in diabetic patients. It is therefore difficult to draw firm conclusions about the optimal antihypertensive strategy for obese patients with type 2 diabetes. Angiotensin-converting enzyme (ACE) inhibitors are certainly effective, and may have other advantages in subjects with cardiovascular disease, nephropathy and retinopathy; they have been shown to reduce complication rates in the UKPDS study (Stearne et al., 1998); angiotensin II receptor blockers have similar effects, and can be used if patients are intolerant of ACE inhibitors, combination with ACE inhibitors may be indicated in patients with microalbuminuria. Low dose thiazide diuretics are safe, but slightly less efficacious than ACE inhibitors - they are a reasonable first-line choice in patients without microalbuminuria. ยก -blockers are certainly effective antihypertensive drugs, but they can cause weight gain, and were less well tolerated than ACE inhibitors in the UKPDS, so should perhaps be considered as second-line agents, although they may be specifically indicated in patients with

10 15 20 25 30 Fat weight (kg)

Figure 10.2 Obese patients respond less well to nifedipine as antihypertensive treatment. Data redrawn from Stoabirketvedt et al. (1995).

10 15 20 25 30 Fat weight (kg)

10 15 20 25 30 Fat weight (kg)

Figure 10.2 Obese patients respond less well to nifedipine as antihypertensive treatment. Data redrawn from Stoabirketvedt et al. (1995).

angina, some dysrhythmias, and in heart failure. Calcium channel blockers seem to be less effective in patients with obesity-related hypertension (Stoabirketvedt et al., 1995), but are useful as add-on therapy (Sharma et al., 2001; Figure 10.2). Other drugs such as a-blockers, methyldopa and clonidine and may have a role as adjunctive therapy where blood pressure is difficult to control.

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