Management of hypertension in overweight and obese patients: A practical guide for clinicians

Abstract

The association between obesity and cardiovascular disease is well established, and up to 60% of overweight or obese patients have hypertension. Dietary interventions associated with modest weight loss are effective in controlling blood pressure and in reducing use of antihypertensive drug therapy in overweight and obese patients. However, long-term maintenance of weight loss is achieved only in a small proportion of patients. Orlistat and sibutramine may help to achieve and maintain weight loss but may not be sufficient to control blood pressure in overweight and obese hypertensive patients. Consequently, antihypertensive drug therapy is often necessary in addition to weight loss interventions. Few studies have investigated different antihypertensive drugs, specifically in overweight and obese patients with hypertension. Based on studies involving obese and nonobese patients, first-line treatment options include a diuretic alone or an angiotensin-converting enzyme (ACE) inhibitor alone. If monotherapy is inadequate for blood pressure control, combination therapy with diuretic and ACE inhibitor and/or combining either of these drugs with a calcium channel blocker are reasonable treatment options. Additional studies to further clarify the management of these patients are warranted.

Effect of Valsartan Addition to Amlodipine on Insulin Sensitivity in Overweight-Obese Hypertensive Patients

“…Although the current guidelines do not give specific recommendations for antihypertensive therapy of obese hypertensive patients, the need to improve the global risk profile in these high risk patients involves optimal pharmacological treatment of obesity hypertension that requires antihypertensive drugs that do not worsen and possibly improve insulin resistance and associated metabolic disturbances, beyond lowering blood pressure (BP) levels (7,8). Furthermore, since the response rates to antihypertensive drug therapy are notoriously low in overweight-obese patients (9,10), two or more antihypertensive agents are requested to reach the BP goal of <140/90 mmHg in these patients.…”

Effect of Delapril/Manidipine vs Olmesartan/ Hydrochlorothiazide Combination on Insulin Sensitivity and Fibrinogen in Obese Hypertensive Patients

“…Current hypertension treatment guidelines stress the role of total risk factor management and state the importance of not only lowering blood pressure (BP) values but also improving the global risk profile of hypertensive patients (8,9). Thus optimal pharmacological treatment of obesity hypertension needs antihypertensive agents that do not exacerbate and possibly improve insulin resistance and the associated metabolic disturbances beyond lowering BP values (10)(11)(12). Furthermore, obesity is associated with the increased likelihood of not achieving goal BP: on a population basis, the probability of lack of BP control in obese hypertensives is about 50% higher than hypertensive patients who are at normal weight (13).…”

“…Therefore, most obese hypertensives will require at least two antihypertensive agents to reach the BP goal of <140/90 mmHg and hypertension treatment guidelines encourage greater use of multidrug therapy especially in difficult to treat hypertension (8). Although (14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25) and diuretics, which counteract increased sodium and fluid retention and cardiac output typical or obesity hypertension (10)(11)(12) …”

Trends in hypertension treatment in diabetes

“…Only two medications, orlistat and sibutramine, have been approved by the US Food and Drug Administration (FDA) for long-term treatment of obesity [19,20]. The FDA recently has been investigating potential hepatotoxicity with orlistat to determine the need for regulatory action [21], lending support to the idea that lifestyle modifi cation, not medication, is the best approach to weight control.…”