title: Blood pressure lowering efficacy of diuretics as second-line therapy for primary hypertension.
abstract: BACKGROUND
  Diuretics are widely prescribed for hypertension not only as a first-line drug but also as a second-line drug. Therefore, it is essential to determine the effects of diuretics on blood pressure (BP), heart rate and withdrawals due to adverse effects (WDAEs) when given as a second-line drug.
  
  
  OBJECTIVE
  To quantify the additional reduction in systolic blood pressure (SBP) and diastolic blood pressure (DBP) of diuretic therapy as a second-line drug in patients with primary hypertension
  
  
  METHODS
  CENTRAL (The Cochrane Library 2008, Issue 2), MEDLINE (1966-July 2008), EMBASE (1988-July 2008) and bibliographic citations of articles and reviews were searched.
  
  
  METHODS
  Double-blind, randomized, controlled trials evaluating the BP lowering efficacy of a diuretic in combination therapy with another class of anti-hypertensive drugs compared with the respective monotherapy (without a diuretic) for a duration of 3 to 12 weeks in patients with primary hypertension.
  
  
  METHODS
  Two review authors independently extracted the data and assessed trial quality.
  
  
  RESULTS
  Fifty-three double-blind RCTs evaluating a thiazide in 15129 hypertensive patients (baseline BP of 156/101 mmHg) were included. Hydrochlorothiazide was the thiazide used in 49/53 (92%) of the included studies. The additional BP reduction caused by the thiazide as a second drug was estimated by comparing the difference in BP reduction between the combination and monotherapy groups. Thiazides as a second-line drug reduced BP by 6/3 and 8/4 mmHg at doses of 1 and 2 times the manufacturer's recommended starting dose respectively. The BP lowering effect was dose related. The effect was similar to that obtained when thiazides are used as a single agent. Only 3 double-blind RCTs evaluating loop diuretics were identified. These RCTs showed a BP lowering effect of a starting dose of about 6/3 mmHg.
  
  
  CONCLUSIONS
  Thiazides when given as a second-line drug have a dose related effect to lower blood pressure that is similar to when they are added as a first-line drug. This means that the BP lowering effect of thiazides is additive. Loop diuretics appear to have a similar blood pressure lowering effect as thiazides at 1 times the recommended starting dose. Because of the short duration of the trials and lack of reporting of adverse events, this review does not provide a good estimate of the incidence of adverse effects of diuretics given as a second-line drug.
authors.affiliation: Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, 2176 Health Sciences Mall, Vancouver, BC, Canada, V6T 1Z3.
authors.forename: Jenny Mh
authors.initials: JM
authors.lastname: Chen
authors.forename: Balraj S
authors.initials: BS
authors.lastname: Heran
authors.forename: James M
authors.initials: JM
authors.lastname: Wright
mesh_terms: D000959:Antihypertensive Agents / Q000627:therapeutic use*; D001794:Blood Pressure / Q000187:drug effects; D004232:Diuretics / Q000627:therapeutic use*; D004359:Drug Therapy, Combination / Q000379:methods; D006339:Heart Rate / Q000187:drug effects; D006801:Humans; D006973:Hypertension / Q000188:drug therapy*; D016032:Randomized Controlled Trials as Topic; D049993:Sodium Chloride Symporter Inhibitors / Q000627:therapeutic use*; D049994:Sodium Potassium Chloride Symporter Inhibitors / Q000627:therapeutic use*
chemical_list: D000959:Antihypertensive Agents; D004232:Diuretics; D049993:Sodium Chloride Symporter Inhibitors; D049994:Sodium Potassium Chloride Symporter Inhibitors