API & ICP issue practical guidelines for doctors to enhance Hypertension care in India

• The guidelines advocate the integration of lifestyle modifications recommending yoga as an adjunct therapy to enhance outcomes

• Specific emphasis laid on using multiple methods to detect and measure hypertension, including at home blood pressure (BP) monitoring

• The guidelines recommend dual therapy, combining Angiotensin Receptor Blockers (ARBs) with newer Calcium Channel Blockers (CCBs) like Cilnidipine, to maximize benefit

August 5, 2024, National: The Association of Physicians of India (API) in collaboration with the Indian College of Physicians (ICP) have released the Guidelines on the Management of Hypertension in Indian Patients with Type 2 Diabetes Mellitus (T2DM). These guidelines address the pressing need for a detailed, region-specific protocol to manage the growing dual burden of hypertension and diabetes in India.

Hypertension and diabetes are among the leading lifestyle diseases in India, contributing significantly to morbidity and mortality. Studies indicate that over 50% of hypertensive patients in India are also diagnosed with T2DM, highlighting a significant overlap that poses unique challenges in patient care. The co-occurrence of these conditions amplifies the risk of cardiovascular complications and accelerates the progression of renal disease, making effective management strategies critical. Also, majority of these diseases are diagnosed and managed at the primary care level in India and thus there is a need for detailed guidelines charting out the entire management protocol, especially in Indian patients.

“While global guidelines provide a framework for managing hypertension in T2DM, the Indian and Southeast Asian populations differ significantly from Western populations in terms of ethnicity, clinical challenges, and drug responses. Recognizing this gap, the API and ICP have collaborated with leading physicians, cardiologists, diabetologists, and endocrinologists to develop a management protocol specifically for Indian patients. The guidelines emphasize the importance of early detection, comprehensive assessment, and a multi-faceted treatment approach” said Dr. Jyotirmoy Pal, President Elect (2025), API

Hypertension in individuals with T2DM greatly increases the risk of cardiovascular complications like heart disease, stroke, and peripheral artery disease. Assessing target organ damage and overall cardiovascular risk is essential to guide treatment intensity and preventive measures. Regular screening for microalbuminuria is recommended to identify those at risk of kidney dysfunction and future cardiovascular disease. Using specialized risk scores developed for individuals with diabetes is preferred over general population risk scores for more accurate cardiovascular risk assessment.

Given the high cardiovascular risk in T2DM, the guideline recommends a treatment of dual antihypertensive therapy, specifically combining Angiotensin Receptor Blockers (ARBs) with Calcium Channel Blockers (CCBs) for their effectiveness in reducing BP and safeguarding against cardiovascular complications.

A notable inclusion in the 2024 guidelines is the recommendation of newer CCBs, with a specific focus on Cilnidipine. Introduced in India in 2007, Cilnidipine has shown promise in offering multiple benefits, not just in reducing BP, but also in protecting crucial organs, especially the kidneys. The guidelines suggest combining Cilnidipine with ARBs to maximize these benefits, while also considering patient-specific factors and comorbidities.

Additionally, Renin-angiotensin system (RAS) blockers should be integral to the treatment regimen, given their proven efficacy in randomized controlled trials (RCTs) for preventing and slowing the progression of diabetic kidney complications. It also recommends use of Newer anti-diabetic agents like SGLT2 inhibitors and GLP-1 receptor to improve glycemic control as well as confer macro & micro- vascular protection.

The API-ICP also recommends conditions where the patients should be further referred to specialists for better management of the disease.

One of the key features of the new guidelines is the emphasis on using multiple methods to detect and measure hypertension, including home blood pressure (BP) monitoring. This approach empowers patients to take an active role in managing their condition, improving adherence to treatment and long-term outcomes.

In addition, the guidelines advocate for the integration of lifestyle modifications to enhance treatment outcomes. For the first time, the ancient Indian practice of yoga is recommended as an adjunct therapy for managing hypertension in T2DM. Doctors are advised to recommend Yoga’s holistic benefits to patients for overall health outcomes.

Healthcare practitioners across India and beyond are encouraged to adopt these guidelines to enhance patient care and ensure the effective management of hypertension in diabetic patients. The guidelines are now available for reference in the Journal of Association of Physicians of India (JAPI), providing a valuable resource for clinicians striving to deliver the highest standard of care.

Dr Jyotirmoy Pal President Elect.API
Org.Secretary & Scientific Chairman, APICON 2025