Management of Hypertension in Patients with Diabetes: A Comprehensive Review of the Perceptions and Practices of Health Care Providers in India

Objectives: This study evaluated the perception and practices of health care providers (physicians, diabetologists, and endocrinologists) regarding the treatment of hypertension in patients with diabetes in India. Methods: Health care providers throughout India who treated patients with diabetes and hypertension were invited to participate in an online survey and periodic 21 virtual meetings. They were questioned about their perception and practices in managing these patients, and strategies to improve blood pressure (BP). Results: The online survey was completed by 2,513 health care providers, and 344 participated in virtual meetings. More than 50% reported that 31–50% of their patients with diabetes also had hypertension. Home BP monitoring was recommended by 88%, and lifestyle modifications were consistently recommended. Choice of antihypertensive treatment varied based on comorbidities, and a renin–angiotensin system blocker plus a calcium channel blocker (CCB) was the most common combination for dual antihypertensive therapy. Suggested strategies to improve BP control included patient awareness/education, lifestyle modifications, better follow-up/monitoring, and optimization of therapy. Conclusion: Indian health care providers were aware of clinical recommendations and practices regarding treatment of patients with diabetes and hypertension, and generally make clinical decisions consistent with current guidelines. Optimization of care for these patients is essential to reduce cardiovascular disease risk and improve patient outcomes.

Atorvastatin improves arterial stiffness in normotensive normolipidaemic persons with type 2 diabetes.

Increased arterial stiffness is an independent predictor of cardiovascular disease and mortality in middle-aged and olderadults. We measured arterial stiffness by pulse wave velocity (PWV)in brachial-ankle segments by automated oscillometry in 71 normotensive and normolipidaemic subjects with type 2 diabetes (40 males and 31 females). 57 patients (whose baPWV was more than 1400 cm/second) were randomised into two groups, group A (n=29) were given 10 mg atorvastatin daily for 6 months and group B (n=28) were given placebo. After 6 months, atorvastatin group had significant improvement in brachial-ankle pulse wave velocity (baPWV) (1712.03 +/- 349.9 cm/second versus 1558.81 +/- 303.26 cm/ second, p< 0.05). Though the placebo group showed some improvement (1692.03 +/- 425.15 cm/second versus 1636.78 +/- 425.1 cm/second) it was not statistically significant. Despite correlation was noted between baPWV and systolic blood pressure (SBP), there was no significant correlation between the mean baPWV and duration of diabetes, body mass index (BMI), waist circumference, waist-hip ratio (WHR), waist to height ratio (WHtR), glycated haemoglobin (HbA1c), LDL, HDL cholesterol and spot urine albumin creatinine ratio (ACR) at the baseline. The decrement of LDL-cholesterol is correlated with the decrement of the baPWV in the atorvastatin group only (p<0.01).

A study of aspirin resistance in type 2 diabetes.

Aspirin is currently known to give inadequate protection against coronary artery disease in diabetes compared to person without it. We evaluated 97 consecutive patients with type 2 diabetes for assessing laboratory aspirin resistance and attempted to assess the impact of various clinical and biochemical parameters on it. Thirty-eight patients (39.1%) were found to be less sensitive to the action of aspirin, 7 persons (7.2%) were found to be resistant and 31 persons (31.9%) were aspirin semi-responders. Only total cholesterol, LDL-cholesterol and triglyceride had statistically significant impact on aspirin resistance (p<0.05). Three persons out of 9 with some form of macrovascular disease had aspirin resistance.

Profile of hypopituitarism in a tertiary care hospital of eastern India--is quality of life different in patients with growth hormone deficiency?

Hypopituitarism is of diverse aetiology. Apart from pituitary adenoma and Sheehan's syndrome, snakebite is a common aetiology of hypopituitarism. A total of 82 patients of hypopituitarism were studied. Biochemical and radiological investigations were done in all the cases. A quality of life questionnaire was put among the patients. Scores were calculated from the answers of the questionnaire and they were assessed about quality of life. Though growth hormone deficiency is associated with poor quality of life there were no significant differences with patients with hypopituitarism without any growth hormone deficiency.

A study on endocrine changes in patients in intensive care unit.

Pattern of endocrine changes in moderate to severely ill patients in a medical intensive care unit, correlation with the severity of illness and whether these changes can predict outcome of the critically ill patients were evaluated and studied in 80 patients admitted with acute physiology and chronic health evaluation (APACHE) II score >10 and without any pre-existing endocrinopathies or on drugs likely to affect the endocrine axis. Adrenal insufficiency was present in 45%, and mortality was higher in those with lower (<15 microg/dl) and higher (>30 microg/dl) serum cortisol. Sick euthyroid syndrome was detected in 80%, and those with low mean T3 (<0.6 ng/ml), free T4 (<0.89 ng/dl) and total T4 (<4 microg/dl) and had increased mortality. Hypotestosteronaemia was found in 92% of men and was significantly associated with severity of illness in men. Though prolactin is the first hormone to be elevated, there was no correlation between prolactin and severity of illness or mortality.

Early treatment with low fixed dose (5 mCi) radioiodine therapy is effective in Indian subjects with Graves' disease.

There is little consensus regarding the most appropriate dosage regimen for radioiodine treatment in Graves' disease. The authors evaluated the efficacy of low fixed dose (5mCi) of radioiodine therapy, in terms of its cure rate and promptness of control, as well possible factors influencing the outcome. One hundred and twenty five consecutive patients with Graves' disease with persistent disease activity despite receiving carbimazole were treated with 5 mCi fixed dose of I131. Patients, who remained hyperthyroid at 1 year, received a second dose of 7.5 mCi of I113. After first dose 73.6% were cured (36.8% hypothyroid and 36.8% euthyroid), while 26.4% patients did not respond. Those who achieved cure had significantly lesser goiter size (84.6% with grade I goiter and 70.7% with grade II) and had received significantly shorter duration of prior carbimazole therapy (22 +/- 10 months versus 63 +/- 27 months) (p < 0.01). Age, sex, baseline T3, T4, 24 hour I131 uptake did not affect the cure rate. Mean time to response was 7 +/- 4 months. One hundred and three (82.4%) patients were cured after 2 doses while only 22 (17.6%) were nonresponsive. Hence, low fixed dose (5mCi) radio active iodine (RAI) therapy seems to be effective in Graves' disease particularly in patients with small sized goiter and short duration of pretherapy with thionamides.

Insulin therapy--role beyond glucose control.

Larger studies had shown improved patient outcome and lower probability of coronary artery disease in insulin treated groups. The classical lipid abnormalities associated with type 2 diabetes are low HDL-cholesterol concentration and high triglyceride concentration. Insulin usage leads to a decrease in triglyceride concentration, primarily by its effect on the enzyme adipose tissue lipoprotein lipase. Insulin suppresses the enzyme, thereby controlling lipolysis in uncontrolled diabetes. Insulins therapy also improves the endothelial dysfunction especially in people with evident macrovascular complications. Though insulin is noted to increase adrenergic tone and may cause elevation of blood pressure, still patients with insulinoma do not have high blood pressure. Some studies suggest weight gain with insulin therapy, others contradict it. One study suggests that insulin does not affect treatment satisfaction. Insulin is known to improve the glycaemic scenario and also the insulin secretory pattern by reducing the glucotoxicity.