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Hypertension
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my personal edition > hypertension > news
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DGDispatch
Diuretics May Be Underused as First-Line Treatment for Patients With Hypertension: Presented at PRI-MED SOUTH
By Jerry Ingram
FORT LAUDERDALE, FL -- April 5, 2004 -- Evidence shows that thiazide diuretics continue to be underused, despite the recommendations made over the last decades by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VII), researchers said here on April 3rd at the Pri-Med South Conference and Exhibition.
"Diuretics remain underutilized in spite of the fact that the JNC-VII for several decades has recommended thiazides as the first therapy and they have a proven track record." said Gerald W. Smetana, MD, division of general medicine and primary care, Beth Israel Deaconess Medical Center, and associate professor of medicine, Harvard Medical School, Boston, Massachusetts.
"In many ways this is a challenging topic to address because it's something that we do so much and so frequently that it becomes mundane," he said. "It's sometimes difficult to think about the things that we think about on a daily basis with the same level of rigor as those areas that we feel somewhat less comfortable with."
Dr. Smetana said he suspects that the hesitancy on the part of some physicians to use thiazide diuretics may be related to information presented in older studies in the 1970's and 1980's, which pointed to increased risk of hypokalemia and subsequent cardiac death. However, he stressed that these studies tested high doses of diuretics. When the studies are "stratified by diuretic dose, a different result emerges," he said.
Low-dose hydrochlorothiazide is equally effective as at higher doses, with very little difference in the level of systolic blood pressure reduction being evident between 12.5 mg and 25 mg daily, Dr. Smetana said.
In addition, he stressed that all antihypertensive drugs may not be equal in terms of their effect on cardiovascular risk. "The most important point that I could make is that all medications that lower blood pressure do not equally reduce cardiovascular risk. This is a very important point," he said.
Citing studies such as the Systolic Hypertension in the Elderly trial and the Swedish Trial in Old Patients With Hypertension 2, he concluded that diuretics are equal to or superior to other medications for all cardiovascular outcomes. Since there may be no advantage to using other more expensive medications, he urged physicians to use diuretics as the first line of therapy unless contraindication or compelling indication for use of another agent is present.
In particular, he noted that African-American and elderly patients are more responsive to diuretics.
Dr. Smetana said that he believes it is important to change the way in which primary care physicians approach hypertension in consideration of the new JNC guidelines.
[Presentation Title: Approach to the Patient With Hypertension.]
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