Thursday, April 07, 2005

ALLHAT Redux: Diuretics "best" for black and Nonblack patients but stay tuned

The data regarding blacks are analyzed in the April 6, 2005 issue of JAMA.The conclusion is that diuretics and CCBs are preferred to ACE inhibitors as initial single drug therapy.The authors in the editorial in the same issue state that -in regard to comparisons of diuretics with other classes of BP lowering drugs-"the issue has been settled". But, it is not settled. ALLHAt compared chlorthalidone, lisinopril and amlodipine but JNC VI and the current editorialists construe the finding broadly to the classes of drugs to which each of the comparison drugs belong.There are problems with that. Cholorthalidone is not widely used (HZCT is), there are several classes of CCBS, and are we really sure that all ACEs are created equal.
The ASCOT trial was recently halted and early reports indicate that the combination of an ACE inhibitor and a CCB was superior to a beta-blocker and a diuretic. When the data are published from this trial, the debate over which BP pills to use will start again, if it ever ended.
The debate should not end because there are scientific questions left to answer and ALLHAT is not the answer to everything for all time.The debate will not end because drug companies have much to gain from sales of ACE inhibitors and ARBs and likely other drugs as well in the future.
There are at least two interesting omissions from the JAMA editorial; 1) the issue of can-or should- the data be extrapolated to other members of the classes of drugs, 2) the issue of low versus high renin hypertension .
The consensus statement of a working group of the International Society on Hypertension in Blacks is -in my opinion-a more reasoned approach than is found in ALLHAT and the above editorial and is more in keeping with the overarching principle that our approaches are provisional, subject to change and are rarely annnoited with apodictic clarity.

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