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Thursday, January 27, 2011

Everybody knows that thiazides are clearly the best anti-hypertensive. On the other hand..

All seven versions of the recommendations of the Joint National Committee for the Prevention, Detection,Evaluation and Treatment of High Blood Pressure (JNC 1 through 7) made it quite clear that thiazides were the drugs of choice for the treatment of hypertension. See here for JNC 7 which says, in part:

"Thiazide-type diuretics should be used for most patients with uncomplicated hypertension either alone or in combination with other drugs."

The ALLHAT trial has been used in support of that recommendation although that trial has generated hundreds if not thousands of pages of rebuttal and re-rebuttal. See here for an ALLHAT summary.We reassured later that the diabetes that sometimes might be precipitated by thiazides is a different and really benign type of diabetes, so not to worry about that.

The European approach is arguably less dogmatic that JNC's emphasis on diuretics.Here is the ESH/ESC 2007 update on hypertension treatment.

Now we have this meta-analysis ( yes, I am very skeptical of MAs in general but when they suit my biases, I shamelessly quote them).See here.

The authors included 14 studies that used 24-hour blood pressure monitoring and concluded"

Conclusions: The antihypertensive efficacy of HCTZ in its daily dose of 12.5 to 25 mg as measured in head-to-head studies by ambulatory BP measurement is consistently inferior to that of all other drug classes. Because outcome data at this dose are lacking, HCTZ is an inappropriate first-line drug for the treatment of hypertension.

Their last sentence could not be more in opposition to JNC. Let the games begin again.


Doug Perednia, MD said...

Ah, Dr. Gaulte! But thiazides ARE the first-line drug to use in EVERY case of hypertension. Why? Because they're dirt cheap. Just like sulfonylureas should ALWAYS be used as the first line drug in Type II diabetes. It doesn't matter that they're not islet sparing and more physiologically sophisticated alternatives may be available. Cheapness trumps all. Guidelines and formularies say it does.

rcentor said...

The hypertension experts I know specifically praise chlorthalidone over hctz. We have probably all made the mistake of equating the chlorthalidone data with hctz substitution.

Perhaps a thiazide (chlorthalidone) is a great first line drug. Our anecdotal experience supports this reasoning.

Anonymous said...

Well, I would not want to argue with expert opinion and anecdotal experience.