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Hydrochlorothiazide as first-line BP therapy less effective than other drug classes

Messerli F. J Am Coll Cardiol. 2011;57:590-600.

Issue: June 2011

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Hydrochlorothiazide as a first-line therapy was inferior to all other drug classes for the reduction of blood pressure, results of a meta-analysis suggested.

Researchers selected 19 randomized studies enrolling 1,463 patients with hypertension for inclusion in the analysis. All studies assessed BP by 24-hour ambulatory monitoring, compared hydrochlorothiazide in a head-to-head fashion with other drug classes and had duration of at least 4 weeks. The primary outcome of interest was a reduction in systolic and diastolic BP from baseline to follow-up.

According to the results, hydrochlorothiazide in the typical dose of 12.5 mg to 25 mg was less effective at lowering systolic BP when compared with angiotensin-converting enzyme (ACE) inhibitors (by 4.5 mm Hg, P=.001), angiotensin receptor blockers (by 5.1 mm Hg, P=.003), beta-blockers (by 6.2 mm Hg, P<.00001) and calcium antagonists (by 4.5 mm Hg, P=.02). For diastolic BP, hydrochlorothiazide was also inferior when compared with ACE inhibitors (by 4 mm Hg, P<.0001), angiotensin receptor blockers (by 2.9 mm Hg, P=.002), beta-blockers (by 6.7 mm Hg, P<.00001) and calcium antagonists (by 4.2 mm Hg, P=.0001).

There was also no difference in systolic (P=.30) or diastolic (P=.15) 24-hour BP reduction between the 12.5-mg dose of hydrochlorothiazide and the 25-mg dose, but the difference in systolic BP became significant at 50 mg (P=.04) when compared with the 25-mg dose.

“Hydrochlorothiazide in its commonly used dose of 12.5 mg to 25 mg daily lowers BP significantly less well than do all other drug classes as measure in head-to-head studies by ambulatory BP monitoring,” Franz H. Messerli, MD, with the Hypertension Program in the Division of Cardiology at St. Luke’s-Roosevelt Hospital, Columbia University College of Physicians and Surgeons, and colleagues concluded. “Because of such paltry antihypertensive efficacy and the lack of outcome data at these doses, physicians should refrain from prescribing hydrochlorothiazide as initial antihypertensive therapy.”

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