N. Rehan, Khurram Nasir


Diabetes mellitus and hypertension are amongst the most common non-communicable diseases in Pakistan effecting nearly 2.7 and 10.8 million individuals respectively1. Both diseases are risk factors for cardiovascular disease and death2. The prevalence of hypertension is double among diabetics as compared to non-diabetics in the western world3. Similar findings have also been reported from Pakistan4. The risk of Cardio-vascular death in a hypertensive diabetic is twice that of a non-diabetic hypertensive and four times that of a non-diabetic without hypertension5. However it is distressing to know that a very low percentage of the Pakistani population is aware as well as treated for these conditions1.

Beta-blockers (β-blockers) are well established in the treatment of coronary heart disease and hypertension6. However until recently they were considered relatively contraindicated among diabetic patient7-10.  A recent meta-analysis by Psaty et al11, which was based on the results of 18 Randomized Controlled Clinical Trials with 50,000 patients, indicated that low dose thiazides (diuretics) and β-blockers are more effective as compared to other agents in reducing total mortality, cardiovascular mortality, stroke and myocardial infarction in individuals with hypertension. The results of this meta-analysis make β-blockers potentially a drug of choice among diabetic individuals with hypertension. Prospective studies have, however, indicated an increased risk of mortality in diabetic patients treated with diuretics12,13. As a result of these findings, the use of diuretics as the first line treatment for hypertension in diabetes mellitus has not been recommended14.

This commentary aims to critically assess the common misconceptions held regarding the use of β-blockers among diabetic hypertensive patients and to explore the recent literature on use of β-blockers among hypertensive diabetic patients.

Full Text:



Pakistan Medical Research Council. National Health Survey of Pakistan. Islamabad : Pakistan Medical Research Council , 1997 : 48,54.

Kaukua J, Turpeinen A, Uusitupa M, Niskanen L. Clustering of cardiovascular risk factors in type 2 diabetes mellitus: prognostic significance and tracking. Diabetes Obes Metab 2001; 3: 17-23

Epstien M, Sowers JR. Diabetes Mellitus and Hypertension. Hypertension 1992;19:403-418

Haider Z, Obaidullah S, Maqbool K. Hypertension in Pakistani patients with diabetes mellitus. J Trop Med Hyg 1980; 83:251-3

Statement on hypertension in diabetes mellitus: Final report. Arch Int Med 1987; 147:830-842

National High Blood Pressure Expert panel working group. Hypertension in Diabetes. Hypertension 1994;23:147-162

Physician Desk Reference, 50th edition. New York : Medical Economics Data Production Company, 1996

Leese GP, Savage MW, Chattington PD, Vora JP. The diabetic patient with hypertension. Postgrad Med J 1996;72:263-268

Kaplan NM. Clinical Hypertension. 6th edition. New York : Williams & Wilkins.

Kaplan NM, Rosetock J, Ruskin P. a differing view of treatment of hypertension in patients with diabetes mellitus. Arch Int Med 1987;147:1160-1162

Psaty BM, Smith NL, Siscovick DS, Koepsell TD, Weiss NS, Heckbert SR, Lemaitre RN, Wagner EH, Furberg CD.. Health outcomes associated with anti-hypertensive therapy used as first-line agents: A systemic review and meta-analysis. JAMA 1997;277:1886-1892

Warram JH, Laffel LM, Valsania P, Christlieb AR, Krolewski AS. Excess mortality associated with diuretic therapy in diabetes mellitus. Arch Int Med 1991;151:1350-1356

Klein R, Klein BE, Moss SE, Davis MD, DeMets DL.. Relation of ocular and systemic factors to survival in diabetes. Arch Int Med 1989;149:266-272

Myers MG, Carruthers SG, Leenen FH, Haynes RB. Recommendations from the Canadian Hypertension Society Consensus Conference on pharmacological treatment of hypertension. CMAJ 1989;140:1141-1146

Report of Medical Research Council Working Party on mild to moderate hypertension. Adverse reactions to bendrofluazide and propanalol for the treatment of mild hypertension. Lancet 1981;2:539-43

Beta Blocker Heart Attack Trial Research Group (BHAT). A randomized clinical trial of propranolol in patients with acute myocardial infarction. JAMA 1982;247:1707-1714

Giugliano D, Acampora R, Marfella R, De Rosa N, Ziccardi P, Ragone R, De Angelis L, D'Onofrio F. Metabolic and cardiovascular effects of carvedilol and atenolol in NIDDM and hypertension: A randomized controlled clinical trial. Ann Int Med 1997;126:955-959

Sowers JR, Zemal MB. Clinicla implications of hypertension in the diabetic patient. Am J Hyper 1990;3:414-424

Heinemann L, Heise T, Klepper A, Ampudia J, Bender R, Starke AA. Four-week administration of an Ace-inhibitor and a cardio selective Beta blocker in healthy volunteers: no influence on insulin sensitivity. Eur J Clin Invest 1995;25: 595-600

Jonas M, Reicher-Reiss H, Boyko V, Shotan A, Mandelzweig L, Goldbourt U, Behar S. Usefulness of beta-blocker therapy in patients with non-insulin diabetes mellitus and coronary artery disease. Am J Cardiol 1996;77:1273-1277

UK Prospective Diabetes Study Group. Efficacy of atenolol and captopril in reducing risks of microvascular and macrovasvular complications in type 2 diabetes mellitus: UKPDS 39. BMJ 1998;317:713-720

Manolio TA, Cutler JA, Furberg CD, Psaty BM, Whelton PK, Applegate WB. Trends in pharmacological management of hypertension in the United States. Arch Int Med 1995;155:829-837

Cruickshank JM, Prichard BNC. Beta-blockers in clinical practice. 2nd edition. New York : Churchill Livingstone, 1994; 950-957

Shorr RI, Ray WA, Daugherty JR, Griffin MR. Antihypertensives and the risk of serious hypoglycemia in older persons using insulin or sulfonylureas. JAMA 1997;278:40-43

Day JL, Metcalf J, Simpson CN. Adrenegenic mechanisms in control of plasma lipid concentrations. BMJ 1982;284:1145-1148

Kasiske BL, Ma JZ, Kalil RS, Louis TA. Effects of anti-hypertensive therapy serum lipid levels. Ann Intern Med 1995;122:133-141

Yusuf S, Peto R, Lewis J, Collins R, Sleight P. Beta-blockade during and after myocardial infarction: an overview of the randomized trials. Prog Cardiovasc Dis 1985 xxvii (5):335-371

Byington RP, Worthy J, Craven T, Furberg CD. Propranolol-induced changes and their prognostic significance after myocardial infarction: the Beta-blocker Heart Attack Trial experiences. Am J Cardiol 1990; 65:1287-1291

Samuelsson O, Hedner T, Persson B, Andersson O, Berglund G, Wilhelmesen L. The role of diabetes mellitus and hypertriglycedemia as coronary risk factor in treated hypertension: 15 years of follow-up of antihypertensive treatment in middle-aged men in the primary prevention trial in Goteberg, Sweden. J Int Med 1994;235;217-227

De Bono G, Kaye CM, Roland E, Summers AJ. Acebutolol : Ten years of experience. Am Heart J 1985;109:1211-1223

Fritz G, Weiner L. Effects of bisoprolol dosed once daily, on blood pressure and serum lipids and HDL cholesterol in patients with mild to moderate hypertension. Eur J Clin pharmacol 1987;32:77

O'Connor R, Persse D, Zachariah B, Ornato JP, Swor RA, Falk J, Slovis CM, Storrow AB, Griswell JK.. Acute coronary syndrome: pharmcotherapy. Prehosp Emerg Care. 2001; 5: 58-64.

Prasad A, Reeder G. Modern adjunctive pharmcotherapy of myocardial infarction. Expert Opin Pharmacother. 2000 ; 1: 405-18

Brachmann J. The role of class III antiarrhythmic agents in maintaining sinus rhythm. Europace. 2000 l;1 Suppl C:C10-5

Gundersen T, Kuekshus J. Timolol treatment after myocardial infarction in diabetic patients. Diabetic Care 1983;6:285-290

Pollare T, Litthle H, Berne C. A comparison of the effects of hydrocholorthiazide and captropril on glucose and lipid metabolism in patients with hypertension. N Eng J Med 1989;321:868-873

Mathiesen ER, Hommel E, Giese J, Parving HH. Efficacy of captropril in postponing nephropathy in normotensive insulin dependent diabetic patients with microalbuminuria. BMJ 1991;303:81-87

Mognensen CE. Angiotensin converting enzyme inhibitors and diabetic nephropathy BMJ 1992;304:327-328

UK Prospective Diabetes Study Group. Tight blood pressure control and risk of microvascular and macrovascular complications in type II diabetes: UKPDS 38. BMJ 1998;317:703-713

Cruickshank JM. Beta-blockers continue to surprise us. Eur Heart J 2000;21:354-363

Philipp T, Anlauf M, Distler A, Holzgreve H, Michaelis J, Wellek S. Randomized, double-blind, multicentre comparison of hydrochlorothiazide, atenolol, nitrendepine and enalapril in antihypertensive treatment, results of the HANE study. BMJ 1997;315:154-159

Preston RA, Materson BJ, Reda DJ, Williams DW, Hamburger RJ, Cushman WC, Anderson RJ. Age-race, subgroup compared with rennin profile as predictors of blood pressure response to antihypertensive therapy. JAMA 1998;279:1168-1172

Dorrow P. Effects of single oral dose of bisoprolol and atenolol on airway functions in non-asthmatic chronic obstructive lung disease and angina pectoris. Eur J Clinic Pharmacol 1986;21: 127-133

Lewis JB, Berl T, Bain RP, Rohde RD, Lewis EJ. The effect of angiotensin converting enzyme inhibition on diabetic nephropathy. N Eng J Med 1993;829;1456-1462

Maschio G, Alberti D, Janin G, Locatelli F, Mann JF, Motolese M, Ponticelli C, Ritz E, Zucchelli P. Effect of the angiotensin converting enzyme inhibitor benazepril on the progression of chronic renal insufficiency. N Eng J Med 1996;334:939-945

Knight EL, Glynn RJ, McIntyre KM, Mogun H, Avorn J. Predictors of decreased renal function in patients with heart failure during ACE-inhibitor therapy; results from the SOLVD study. Am Heart J 1999; 138: 849-855

Croog SH, Levine S, Testa MA, Brown B, Bulpitt CJ, Jenkins CD, Klerman GL, Williams GH. The effects of antihypertensives on quality of life. N Eng J Med 1986;314:1657-1664

Steiner SS, Friedhoff AJ, Wilson BL, Wecker JR, Santo JP. Antihypertensive therapy and quality of life; a comparison of atenolol, captropril, enalapril and propranolol. J HumHypertens 990;4:217-225

Fletcher AE, Bulpitt CJ, Hawkins CM. Quality of life on antihypertensive therapy; a randomized double blind controlled trial of atenolol and captropril. J Hyper 1990;8: 463-466

Prichard BNC, Saul PA. Comparison of beta blockade and ACE inhibition in the treatment of hypertension. J Cardiovasc Pharmcol 1989; 16 (Suppl 15): 81-85


  • There are currently no refbacks.

Contact Number: +92-992-382571

email: [jamc] [@] []