A 44-year-old man comes to the physician for hypertension follow-up. Systolic blood pressure readings during his prior visits ranged from 150-160 mm Hg and diastolic readings were 90-100 mm Hg. Medical history is significant for right knee osteoarthritis. He has a strong family history of type 2 diabetes mellitus and stroke.
Blood pressure is 158/95 mm Hg and pulse is 78/min. BMI is 31.5 kg/m². Physical examination shows central obesity but is otherwise unremarkable.
Complete blood count, basic metabolic panel, and urinalysis show no significant abnormalities except for serum glucose of 110 mg/dL. Fasting lipid panel shows low-density lipoprotein of 110 mg/dL and triglycerides of 185 mg/dL.
Use of which of the following medications is associated with the highest risk of developing diabetes mellitus in this patient?

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11ec193a_9768_11a5_853d_f780af70b3c3_MD0002_00 Thiazide diuretics can raise blood glucose levels due to a dose-dependent decrease in pancreatic insulin release and impairment of glucose uptake in peripheral tissues. These medications are associated with an increased risk of developing diabetes mellitus compared to other first-line antihypertensive medications (eg, ACE inhibitors, calcium channel blockers). In patients who already have diabetes mellitus, thiazide diuretics can lead to impaired glycemic control. They also can raise serum LDL and triglyceride levels. Thiazides are not usually used as first-line antihypertensive agents in patients with diabetes mellitus. However, despite the effects on glucose, thiazides are beneficial (typically as an add-on medication) due to their antihypertensive efficacy and reduced risk of cardiovascular events (eg, stroke). (Choice A) Although some beta blockers (eg, atenolol, metoprolol) are associated with hyperglycemia, vasodilating beta blockers (eg, carvedilol, labetalol) are not linked to an increased risk of diabetes mellitus. (Choices C and D) ACE inhibitors (eg, lisinopril) and angiotensin II receptor blockers (eg, losartan) are preferred as first-line antihypertensive therapy in most patients with diabetes mellitus because they can reduce progression of early diabetic nephropathy. Neither has a significant effect on glucose or lipid metabolism. (Choice E) Calcium channel blockers (eg, nifedipine) have a minimal effect on glucose metabolism. Educational objective: Thiazide diuretics can cause hyperglycemia and are associated with an increased risk of diabetes mellitus. They are not typically used as first-line antihypertensive agents in patients with diabetes mellitus but are beneficial as add-on therapy due to their antihypertensive efficacy and reduced risk of cardiovascular events (eg, stroke). __________ References: What should be the antihypertensive drug of choice in diabetic patients and should we avoid drugs that increase glucose levels? Pro and cons. (http://www.ncbi.nlm.nih.gov/pubmed/23280868) Type of beta-blocker use among patients with versus without diabetes after myocardial infarction. (http://www.ncbi.nlm.nih.gov/pubmed/25173537)

A 44-Year-Old Man Comes to the Physician for Hypertension Follow-Up