Antihypertensive Treatment in Diabetes

The systolic hypertension in the Elderly (SHEP) trial was a double-blind, randomized, placebo-controlled trial in 4736 men and women aged 60 years and older with isolated systolic hypertension, defined as systolic blood pressure above 160 mmHg, and diastolic blood pressure below 90 mmHg. Among this population, there were 583 non-insulin-dependent diabetic patients.

Noting that, in one observational study, diuretic treatment of diabetic hypertensives was associated with increased risk of morbidity and mortality, and that glucose, total cholesterol, and LDL-cholesterol adversities have been seen in some trials of diuretic therapy, Curb et al examined the five-year rates of major cardiovascular disease events, nonfatal plus fatal stroke, nonfatal myocardial infarction, major coronary heart disease events, and all-cause mortality in the diabetic subset of the SHEP population.

Chlorthalidone (12.5-25.0 mg/d) was the initial treatment, with atenolol or reserpine added if needed. Both diabetic and nondiabetic patients experienced lower cardiovascular disease rates (by 34%) in the active treatment group than the placebo group. Absolute risk reduction with active treatment was actually two times greater for diabetic than nondiabetic patients, due to the higher risk in diabetics. The authors conclude that low-dose diuretic-based therapy is effective in diabetic as well as nondiabetic older patients with isolated systolic hypertension.

Curb D, et al. JAMA 1996;276: 1886-1892.