Hypertension in the elderly diabetic: therapeutic aspects.

Elderly diabetic patients with hypertension present a difficult medical management problem. The guidelines published by the 1987 Working Group on Hypertension in Diabetes in the United States suggest a stepped care approach to drug therapy in these patients. The stepped care strategy is to add a series of antihypertensive medications sequentially until the blood pressure is controlled. The first step includes one of the following: thiazide diuretics, beta-blockers, alpha-adrenergic inhibitors, angiotensin converting enzyme (ACE) inhibitors or calcium channel blockers. The second step adds a second agent from the same group, while the third step adds a vasodilator and step four adds a drug like guanethidine if the combination of other drugs fails. This approach presents many perils in the aged patient with diabetes. In these patients the physician should: (1) limit the use of diuretics and beta-blockers; (2) favour the use of calcium channel blockers and ACE inhibitors; (3) use a substitution approach rather than a stepped care approach; and (4) use monotherapy if possible.