Lessons from ALLHAT. Are low budget diuretics first line therapy in hypertension?
Diuretics are well-established and nowadays also cheap cardiovascular agents. In contrast to the most recent American hypertension guidelines (JNC 7) which ascribe a singular place to diuretics in the first-line treatment of hypertension following a one-sided interpretation of the ALLHAT results, in the balanced guidelines of the European Society of Hypertension (ESH) published in 2003, they are placed alongside beta-blockers, ACE inhibitors, sartans and calcium antagonists as the drugs of first choice, but not given preference. Previous scientific evidence and clinical experience is to a certain extent in line with this classification of diuretics. On the basis of the indisputable dose-dependent potential for side-effects such as hypokalaemia, diabetogenicity and stimulation of neurohumoural systems, I personally consider diuretics to be inferior to the more recent substance groups, particularly the RAS inhibitors. I would therefore welcome it if diuretics in the future were removed from the monotherapy of hypertension and offered from the outset as low-dosed combination partners for RAS inhibitors, beta-blockers and also calcium antagonists. In this role they could only do good and not cause any damage.
Unger
T
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Center for Cardiovascular Research/Institut für Pharmakologie und Toxikologie, Charité-Universitätsmedizin Berlin, Hessische Strasse 3-4, 10117 Berlin, Germany. thomas.unger@charite.de
D000959:Antihypertensive Agents / Q000009:adverse effects* / Q000191:economics / Q000627:therapeutic use*; D002986:Clinical Trials as Topic / Q000379:methods*; D003920:Diabetes Mellitus / Q000139:chemically induced; D004232:Diuretics / Q000009:adverse effects* / Q000191:economics / Q000627:therapeutic use*; D004305:Dose-Response Relationship, Drug; D005060:Europe; D019317:Evidence-Based Medicine / Q000379:methods; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000188:drug therapy* / Q000191:economics; D007008:Hypokalemia / Q000139:chemically induced / Q000191:economics; D009203:Myocardial Infarction / Q000191:economics / Q000209:etiology / Q000517:prevention & control; D010346:Patient Care Management / Q000191:economics / Q000379:methods / Q000592:standards; D017410:Practice Guidelines as Topic; D014481:United States
D000959:Antihypertensive Agents; D004232:Diuretics