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Diuretics and diabetes
- Paul J. Rosch (4 September 2003)
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An unpoetic POEM
- Kjell Midtbø (8 October 2003)
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Poetic Atlantic gap.
- Hans J.M. Van Brabandt (26 October 2003)
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Paul J. Rosch, Clinical Professor of Medicine and Psychiatry, New York Medical College 124 Park Ave, Yonkers, NY 10703 USA
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I would question the contention that thiazide diuretics "should be first line treatment for almost everyone with hypertension, including patients with diabetes" for several reasons. The ALLHAT study, on which JNC-VII recommendations were largely based, showed a disturbing 11.6% incidence of new diabetes for every 4 years of daily chlorthalidone. One might therefore anticipate an even more alarming increase in diabetes in hypertensive patients who would continue to take thiazides for decades under the latest guidelines. This is of particular concern since diabetes is now considered to be a risk for heart attack of the same magnitude as evidence of existing coronary artery disease. In addition, it is estimated that up to a third of diabetic patients will develop chronic renal failure that eventually requires dialysis or a kidney transplant. Diuretics can also cause interstitial nephritis, are the most common cause of dehydration in diabetic nephropathy and are contraindicated in chronic renal failure, so that their continued administration as suggested could really wreak havoc. The reference cited[1] not only does not support the use of diuretics in diabetic hypertensives but actually indicates that ACE inhibitors may be preferable, citing a paper by some of the same authors.[2] In contrast to thiazides, studies show that ACE inhibitors and
angiotensin receptor blockers, another class of antirenin drugs are
beneficial in diabetic nephropathy. Indeed, the angiotensin II receptor
blocker (ARB) irbesartan was recently approved for the treatment of
diabetic nephropathy in hypertensives with type 2 diabetes, and losartan,
another ARB, has now been shown to reduce albuminuria in type 2 diabetes.
1. Psaty BM, Lumley T, Furberg CD, et al. Health outcomes associated
with various antihypertensive therapies used as first-line agents. A
network meta-analysis. JAMA 2003;289: 2534-44.
2. Pahor M, Psaty BM, Alderman MH, Applegate WB, Williamson JD,
Furberg CD. Therapeutic benefits of ACE inhibitors and other
antihypertensive drugs in patients with type 2 diabetes. Diabetes Care.
2000;23:888-892
Competing interests:
None declared |
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Kjell Midtbø, Consultant cardiologist Ulleval University Hospital, Oslo
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When I read the POEM in BMJ vol. 327,30 August 2003,at the end of "Bottom line", I could not believe what I was reading: "Anyone who continues to prescribe a calcium channel blocker(dr.Furberg`s former "crusade" target) as a first line agent for uncomplicated hypertension should have their car trunk checked for large amounts of drug company paraphernalia and interrogated about who paid for their dinner the night before" !! Who is saying this,BMJ or one of the authors of ALLHAT? In my opinion this is a serious accusation,offensive,nearly defamatory.At best this utterance is rude and impudent. Shame on the person who wrote this! According to current guidelines from ISH/ESC(2003),all main groups of antihypertensives(beta-blockers,diuretics,calcium channel blockers,and ACE inhibitors) can be prescribed as first line treatment.And these guidelines have been written after the publishing of ALLHAT,a study with several flaws (no proper end point committee (!),insufficient diagnostic criteria of heart failure etc)which has been commented on on several occasions. If I were to be as audacious as the Bottom line commentator (the authors of ALLHAT?),I could ask him/her which (budget) politician he/she is dining with.But I wouldn`t dream of being that impertinent. Competing interests: None declared |
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Hans J.M. Van Brabandt, MD, cardiologist B2800 Mechelen, Belgium
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This POEM suggests a worldwide consensus regarding treatment of high blood pressure but a wide gap remains between expert opinion on both sides of the Atlantic. Although based upon the same scientific literature, the JNC7-report and the 2003 European Society of Hypertension–European Society of Cardiology guidelines end up with a different advice. Nonetheless, the POEM, which copies the Anglosaxon point of view, claims the highest level of evidence. The JNC7 guidelines are based on the results of 42 clinical trials, including ALLHAT, the largest randomised hypertension trial ever. The authors conclude that thiazide-type diuretics should be considered first for pharmacologic therapy in patients with hypertension. European Guidelines on the other hand promote a tailored approach in treating hypertension, taking into account associated risk factors and co-morbid conditions. I believe the Anglosaxon and Continental guidelines could be reconciliated resulting in a useful algorithm. This will prevent Spanish doctor’s cars being screened for drug company paraphernalia when prescribing doxazosin, the most commonly used antihypertensive in Spain. In the same way, Scandinavian patients won’t be forced to emigrate from their homeland, chlorthalidone being banned out from the Scandinavian pharmaceutical market. Considering that lowering blood pressure per se is of utmost importance, that the major antihypertensive classes all have shown to be effective, given the fact that in JNC7 the ALLHAT results are over- represented and that previous studies suggest that the response to antihypertensives is more or less predictable as a function of age (ABCD- rule) and considering that most older patients need more than one antihypertensive agent, I propose the following: 1. In low-risk young patients, initiate antihypertensive medical treatment with an ACE-inhibitor (A) or a beta-blocker (B). If the desired level of blood pressure reduction is not achieved, a low dose diuretic (D) should be added as a second step. 2. In patients older than 50 years, start with a rational combination of a low dose diuretic and a second drug, the nature of which depends on patient specific factors and co-morbidities. Competing interests: None declared |
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