If you’re living with type 2 diabetes, your risk of developing hypertension — or high blood pressure — is twice as high as that of the general public. If you have hypertension with diabetes, you have a 16 percent chance of developing resistant hypertension. That means your blood pressure remains high, even though you’re taking blood pressure medications.

High blood pressure is a serious condition that increases your risk for life-threatening conditions such as heart attack, stroke, and kidney disease. If you’re living with diabetes, it’s important to talk to your doctor about your individual risk factors for hypertension and resistant hypertension and how these conditions can be managed.

There are reasons why people with diabetes have a higher risk of having high blood pressure that, in some cases, may become resistant to treatment. Here’s information on diabetes and resistant hypertension that you can discuss in more detail with your healthcare team.

What Is Resistant Hypertension?

Resistant hypertension occurs when your blood pressure reading is 140/90 millimeters of mercury (mm Hg) or higher, despite taking the maximum recommended dosage of three or more blood pressure medications. People with resistant hypertension have typically tried a combination of these three medicines:

• A diuretic, also known as a water pill, to help eliminate water and salt through urine
• A calcium channel blocker to control how the body uses calcium
• An angiotensin 2 receptor blocker (ARB) or angiotensin-converting enzyme (ACE) inhibitor to help block agents that can cause blood vessels to narrow

If these blood pressure drugs don’t effectively lower blood pressure after six months of treatment, the condition is considered resistant hypertension. A number of factors can contribute to resistant hypertension, including:

• Having a high body weight
• Not getting enough physical activity
• Eating foods that are high in salt
• Drinking high amounts of alcohol
• Taking medications such as painkillers, birth control pills, nasal decongestants, and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen
• Taking herbal products such as licorice and ginseng

Health conditions such as sleep apnea and chronic kidney disease can also cause resistant hypertension. Women, African Americans, and people with diabetes have a higher risk of developing resistant hypertension, according to the Cleveland Clinic.

About 40 percent of people with resistant hypertension have not actually taken the medications at the doses and times that would be most effective. In these cases of poorly managed hypertension, the condition is known as pseudoresistant hypertension. This means that blood pressure would likely be controlled if people maintained their treatment plans or received better medical care.

How Diabetes Increases the Risk of Hypertension and Resistant Hypertension

Diabetes and hypertension have some of the same characteristic risk factors. Because of this, people with diabetes have an increased risk of developing high blood pressure, and people with hypertension have a higher risk of developing type 2 diabetes.

Insulin Resistance

Both diabetes and hypertension are associated with insulin resistance, a condition in which the body can’t make or use insulin effectively. Insulin is a hormone that regulates glucose (blood sugar). It allows blood sugar to move into the body’s cells and provide the energy the cells need to function properly.

Insulin resistance can affect the vascular system — the body’s network of blood vessels — and cause problems that affect blood flow and blood pressure, such as:

• Endothelial dysfunction — Narrowing of blood vessels
• Stiffened arteries
• Atherosclerosis — A buildup of fat and cholesterol in the arteries
• Vascular inflammation

Because of these risks, people with diabetes are more prone to hypertension than the general public. Some research has shown that people with diabetes and the general public have similar rates of resistant hypertension. However, there’s some evidence that resistant hypertension with diabetes may cause an increase in diabetes-related complications, including:

• Neuropathy — Nerve damage
• Retinopathy — Damage to the blood vessels in the eyes that can lead to blindness
• Chronic kidney disease
• Cardiovascular disease

Fluid and Salt Retention

Diabetes can damage the kidneys, which is why chronic kidney disease is a serious complication of diabetes. Kidney damage can prevent the body from removing excess water and salt from the body, which often causes edema (swelling), primarily in the legs, feet, and around the eyes. Fluid and salt retention can cause high blood pressure and commonly leads to resistant hypertension in people with chronic kidney disease.

Obesity

Obesity (high body weight) is a major risk factor for developing hypertension. Approximately 75 percent of people with primary high blood pressure — blood pressure that isn’t caused by another condition — also have a higher body weight.

About 90 percent of people with type 2 diabetes are considered obese or overweight, according to a study in Clinical Medicine. People who have a higher body weight have higher amounts of visceral fat and white fat, which puts pressure on the vascular system and organs, including the heart and kidneys.

Sleep Apnea and Diabetes

There’s a high prevalence of sleep apnea with diabetes. Approximately 60 percent of people with diabetes also have obstructive sleep apnea (OSA). Both conditions are linked to obesity and metabolic syndrome. Obstructive sleep apnea is a condition in which the upper airway becomes blocked during sleep and disrupts breathing and sleep throughout the night.

In people with sleep apnea, interruptions in breathing cause a drop in oxygen, which causes stress in the body’s cardiovascular system and can lead to high blood pressure. Sleep apnea is also the health condition that’s most commonly associated with resistant hypertension.

Treatment of Resistant Hypertension With Diabetes

Resistant hypertension can be challenging to manage, but advancements in treatment approaches can be effective for blood pressure control in many people who have both diabetes and resistant hypertension. Treatment of resistant hypertension requires a personalized approach that considers your individual health with strategies that include:

• A combination of medications
• Healthy lifestyle changes
• Management of underlying health conditions, such as sleep apnea or chronic kidney disease
• Adherence to your treatment plan

Medications

If you have resistant hypertension, your doctor may need to try different combinations of antihypertensive medication (drugs that treat high blood pressure).

More recently, a class of drugs known as mineralocorticoid receptor antagonists (MRAs) — also known as aldosterone receptor antagonists — was found to be effective in the treatment of resistant hypertension in people with diabetes and resistant hypertension. Your doctor may recommend this drug in addition to other medications.

Diuretics are an important medication for people with both diabetes and resistant hypertension. MRAs, such as spironolactone, are a type of potassium-sparing diuretic. This type of diuretic may require monitoring if you’re at risk of developing hyperkalemia, a condition in which too much potassium is in the blood.

Other drugs that are considered good for treating hypertension with diabetes in some people include:

• ACE inhibitors
• ARB medications
• Angiotensin receptor-neprilysin inhibitors
• Beta-blockers
• Calcium channel blockers

Always discuss potential side effects with your doctor before starting a new medication.

Lifestyle Changes

Healthy lifestyle adjustments are also important for managing resistant hypertension, including:

• Maintaining a healthy weight
• Getting regular exercise and physical activity
• Avoiding excessive alcohol
• Reducing the consumption of salt
• Quitting smoking, which raises the risk of heart disease

The DASH (Dietary Approaches to Stopping Hypertension) eating plan is a heart-healthy diet that recommends:

• Getting lots of fruits, vegetables, and whole grains
• Eating lean proteins, such as low-fat dairy, poultry, fish, beans, and nuts
• Limiting foods with added sugar
• Avoiding fatty meats and other foods high in saturated fat

Your doctor can give you a referral to a registered dietitian if you need help with healthy meal planning.

Talk to Your Doctor

Your doctor can advise you on how to help prevent hypertension and how best to manage hypertension and resistant hypertension. It’s essential to maintain your diabetes care and treatment plan for any other health conditions you may have, including hypertension and resistant hypertension.

If you’re not happy with your treatment plan, be sure to talk to your doctor before making any changes in your medications.

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