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Prescribing Advice for GPs

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Thiazides first for hypertension?

The Archives of Internal Medicines has published a subgroup analysis of the ALLHAT study examining the rate of cardiovascular outcomes in patients with metabolic syndrome.

The analysis was performed on patients with metabolic syndrome, defined as hypertension and at least two of the following:

  • Body Mass Index greater than 30kg/M2
  • Fasting glucose greater than 5.6mmol/L
  • Triglycerides greater than 1.7mmol/L
  • HDL less than 1.0mmol/L for a man and 1.3mmol/L for a woman

The analysis compared all four study drugs (chlorthalidone, amlodipine, lisinopril and doxazosin) and also studied black and non-black patients in separate groups.

The analysis found significantly higher rates of heart failure for all drugs and irrespective of ethnicity when compared to the chlorthalidone. There was also an increased risk of combined cardiovascular disease for the lisinopril and doxazosin groups irrespective of ethnicity. Finally, there was a higher stroke rate in black patients in the lisinopril and doxazosin groups and end-stage renal disease in black patients in the lisinopril group.

The authors conclude that, "the ALLHAT findings fail to support the preference for calcium channel blockers, alpha-blockers, or angiotensin-converting enzyme inhibitors compared with thiazide-type diuretics".

Action: This analysis adds weight to the positioning of thiazides as first line antihypertensives in the vast majority of patients with hypertension. Clinicians should consider their current practice in comparison to the recommendations made by the National Institute of Health and Clinical Excellence.

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2 Comments to “Thiazides first for hypertension?”

  1. Minto,

    This analysis was conducted on the ALLHAT study which used chlorthalidone as the thiazide drug for the study. This choice is based on market share usage in America.

    In Britain, bendroflumethiazide is the most popular thiazide and of course it was studied in ASCOT. Of course ASCOT wasn't as favourable in terms of outcomes but there are limitations to the study when looking at the doses of thiazide and beta blocker used. Additionally, indapamide has been studied in the PROGRESS study.

    So, should you continue to use what you know and are comfortable with or changed to the thiazide used in ALLHAT. There is no clear evidence that there are differences between these drugs so continuing with bendroflumethiazide would seem a rational choice.

    Comment by Matthew Robinson — February 6, 2008 #

  2. the subgroup analysis supports the use of chlorthalidone. however is this a class effect and is bendroflumethiazide the same? are all thiazide diuretics the same? where is the evidence for bendroflumethiazide?

    Comment by minto — February 5, 2008 #

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