News - Hypertension Week of May 18, 2003/ Vol. 2 No. 20

Experts Criticize Recommendation That Most Patients Use Diuretics

Hypertension experts criticized a recommendation in the new blood pressure guidelines issued by the National Heart, Lung and Blood Institute that diuretics be used to treat high blood pressure in most patients.

The recommendation appears in the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) issued May 14 (see related story).

In editorials published in the May issue of the American Journal of Hypertension, the experts claim that the diuretic recommendation was based on a "faulty" study called ALLHAT (Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial).

"In reading JNC 7, I find its recommendations bad medicine," said Dr. John H. Laragh, editor-in-chief of the American Journal of Hypertension and a research pioneer into the root causes of hypertension. "ALLHAT and JNC 7 recommendations constitute a large step backward for the better understanding and treatment of hypertension. JNC 7 misleads doctors by encouraging them to adopt a one-drug-fits-virtually-all approach."

Laragh, a cardiologist, said giving the diuretic chlorthalidone to every hypertensive patient, as ALLHAT authors advise, could well be the wrong first drug more than half the time and would lead to unnecessary multiple drug use. He also noted that the study perpetuates the "fallacious premise that all human hypertension is alike."

"There are two different types of hypertension: one dependent on too much salt and the other on too much action of the hormone, renin, in the blood," explained Dr. Laragh. "The appropriate first treatment is quite different, a diuretic in one case and an anti-renin drug in the other."

Laragh said recognizing these two treatment differences and following the appropriate treatment regimen would have "most patients… on their way to correcting their high blood pressure for life by taking only one drug."

Dr. Lawrence M. Resnick, also an American Journal of Hypertension editor, wrote that ALLHAT could have reasonably concluded that ACE inhibitors should be the antihypertensive drug of first choice since their outcomes were equal to those obtained with the diuretic.

Resnick, an endocrinologist, said diuretics should not be the drug of first choice in many hypertension patients because of side effects associated with increased mortality and morbidity over periods longer than those studied in ALLHAT.

Other sources: American Society of Hypertension