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Ernst ME, Fravel MA. Thiazide and the Thiazide-Like Diuretics: Review of Hydrochlorothiazide, Chlorthalidone, and Indapamide. Am J Hypertens 2022; 35:573-586. [PMID: 35404993 DOI: 10.1093/ajh/hpac048] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/05/2022] [Indexed: 01/27/2023] Open
Abstract
The term thiazide is universally understood to refer to diuretics that exert their principal action in the distal tubule. The thiazide class is heterogenous and can be further subdivided into compounds containing the benzothiadiazine ring structure-the thiazide-type (e.g., hydrochlorothiazide)-and those lacking the benzothiadiazine ring-the thiazide-like (e.g., chlorthalidone and indapamide) drugs. Thiazide-like agents are longer acting and constitute the diuretics used in most of the cardiovascular outcome trials that established benefits of treatment with diuretics, but pragmatic aspects, such as lack of availability in convenient formulations, limit their use. Regardless of class heterogeneity, thiazides have retained importance in the management of hypertension for over 60 years. They are reliably effective as monotherapy in a majority of hypertensive patients, and augment the efficacy of other classes of antihypertensives when used in combination. Importantly, a thiazide-based treatment regimen lowers cardiovascular events, and their sturdy effect reinforces their place among the recommended first-line agents to treat hypertension in major domestic and international hypertension guidelines. There are few head-to-head comparisons within the class, but potential differences have been explored indirectly as well as in non-blood pressure mechanisms and potential pleiotropic properties. Until proven otherwise, the importance of these differences remains speculative, and clinicians should assume that cardiovascular events will be lowered similarly across agents when equivalent blood pressure reduction occurs. Thiazides remain underutilized, with only about one-third of hypertensive patients receiving them. For many patients, however, a thiazide is an indispensable component of their regimen to achieve adequate blood pressure control.
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Affiliation(s)
- Michael E Ernst
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Iowa, Iowa City, Iowa, USA.,Department of Family Medicine, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Michelle A Fravel
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Iowa, Iowa City, Iowa, USA
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Messerli FH, Rimoldi SF, Mann SJ. Safety and Efficacy of Thiazide Diuretics in Hypertension. Am J Med 2022; 135:e109. [PMID: 35525564 DOI: 10.1016/j.amjmed.2021.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 10/23/2021] [Indexed: 11/01/2022]
Affiliation(s)
- Franz H Messerli
- Swiss Cardiovascular Center Inselspital University of Bern Switzerland.
| | - Stefano F Rimoldi
- Swiss Cardiovascular Center Inselspital University of Bern Switzerland
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Messerli FH, Roush GC, Oparil S. Chlorthalidone and Hydrochlorothiazide for Treatment of Patients With Hypertension. JAMA Intern Med 2020; 180:1133. [PMID: 32568361 DOI: 10.1001/jamainternmed.2020.1742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Franz H Messerli
- Swiss Cardiovascular Center, University of Bern, Bern, Switzerland
| | | | - Suzanne Oparil
- Division of Cardiovascular Disease, University of Alabama at Birmingham
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Brainin M, Feigin V, Bath PM, Collantes E, Martins S, Pandian J, Sacco R, Teuschl Y. Multi-level community interventions for primary stroke prevention: A conceptual approach by the World Stroke Organization. Int J Stroke 2019; 14:818-825. [DOI: 10.1177/1747493019873706] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The increasing burden of stroke and dementia emphasizes the need for new, well-tolerated and cost-effective primary prevention strategies that can reduce the risks of stroke and dementia worldwide, and specifically in low- and middle-income countries (LMICs). This paper outlines conceptual frameworks of three primary stroke prevention strategies: (a) the “polypill” strategy; (b) a “population-wide” strategy; and (c) a “motivational population-wide” strategy. (a) A polypill containing generic low-dose ingredients of blood pressure and lipid-lowering medications (e.g. candesartan 16 mg, amlodipine 2.5 mg, and rosuvastatin 10 mg) seems a safe and cost-effective approach for primary prevention of stroke and dementia. (b) A population-wide strategy reducing cardiovascular risk factors in the whole population, regardless of the level of risk is the most effective primary prevention strategy. A motivational population-wide strategy for the modification of health behaviors (e.g. smoking, diet, physical activity) should be based on the principles of cognitive behavioral therapy. Mobile technologies, such as smartphones, offer an ideal interface for behavioral interventions (e.g. Stroke Riskometer app) even in LMICs. (c) Community health workers can improve the maintenance of lifestyle changes as well as the adherence to medication, especially in resource poor areas. An adequate training of community health workers is a key point. Conclusion An effective primary stroke prevention strategy on a global scale should integrate pharmacological (polypill) and lifestyle modifications (motivational population-wide strategy) interventions. Side effects of such an integrative approach are expected to be minimal and the benefits among individuals at low-to-moderate risk of stroke could be significant. In the future, pragmatic field trials will provide more evidence.
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Affiliation(s)
- Michael Brainin
- Department for Clinical Neuroscience and Preventive Medicine, Danube University Krems, Krems, Austria
| | - Valery Feigin
- National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, School of Public Health and Psychosocial Studies, Auckland, New Zealand
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, UK
| | - Epifania Collantes
- Department of Neurosciences, Philippine General Hospital, Manila, Philippines
| | - Sheila Martins
- Neurology and Neurosurgery Service, Hospital Moinhos de Vento, Brazil
| | - Jeyaraj Pandian
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Ralph Sacco
- Miller School of Medicine, University of Miami, FL, USA
| | - Yvonne Teuschl
- Department for Clinical Neuroscience and Preventive Medicine, Danube University Krems, Krems, Austria
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Latek D, Rutkowska E, Niewieczerzal S, Cielecka-Piontek J. Drug-induced diabetes type 2: In silico study involving class B GPCRs. PLoS One 2019; 14:e0208892. [PMID: 30650080 PMCID: PMC6334951 DOI: 10.1371/journal.pone.0208892] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 11/27/2018] [Indexed: 01/10/2023] Open
Abstract
A disturbance of glucose homeostasis leading to type 2 diabetes mellitus (T2DM) is one of the severe side effects that may occur during a prolonged use of many drugs currently available on the market. In this manuscript we describe the most common cases of drug-induced T2DM, discuss available pharmacotherapies and propose new ones. Among various pharmacotherapies of T2DM, incretin therapies have recently focused attention due to the newly determined crystal structure of incretin hormone receptor GLP1R. Incretin hormone receptors: GLP1R and GIPR together with the glucagon receptor GCGR regulate food intake and insulin and glucose secretion. Our study showed that incretin hormone receptors, named also gut hormone receptors as they are expressed in the gastrointestinal tract, could potentially act as unintended targets (off-targets) for orally administrated drugs. Such off-target interactions, depending on their effect on the receptor (stimulation or inhibition), could be beneficial, like in the case of incretin mimetics, or unwanted if they cause, e.g., decreased insulin secretion. In this in silico study we examined which well-known pharmaceuticals could potentially interact with gut hormone receptors in the off-target way. We observed that drugs with the strongest binding affinity for gut hormone receptors were also reported in the medical information resources as the least disturbing the glucose homeostasis among all drugs in their class. We suggested that those strongly binding molecules could potentially stimulate GIPR and GLP1R and/or inhibit GCGR which could lead to increased insulin secretion and decreased hepatic glucose production. Such positive effect on the glucose homeostasis could compensate for other, adverse effects of pharmacotherapy which lead to drug-induced T2DM. In addition, we also described several top hits as potential substitutes of peptidic incretin mimetics which were discovered in the drug repositioning screen using gut hormone receptors structures against the ZINC15 compounds subset.
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Affiliation(s)
- Dorota Latek
- Faculty of Chemistry, University of Warsaw, Warsaw, Poland
| | | | | | - Judyta Cielecka-Piontek
- Department of Pharmacognosy, Faculty of Pharmacy, Poznan University of Medical Sciences, Poznan, Poland
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Das P, Delost MD, Qureshi MH, Smith DT, Njardarson JT. A Survey of the Structures of US FDA Approved Combination Drugs. J Med Chem 2018; 62:4265-4311. [DOI: 10.1021/acs.jmedchem.8b01610] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Pradipta Das
- Department of Chemistry & Biochemistry, University of Arizona, 1306 East University Boulevard, Tucson, Arizona 85721, United States
| | - Michael D. Delost
- Department of Chemistry & Biochemistry, University of Arizona, 1306 East University Boulevard, Tucson, Arizona 85721, United States
| | - Munaum H. Qureshi
- Department of Chemistry & Biochemistry, University of Arizona, 1306 East University Boulevard, Tucson, Arizona 85721, United States
| | - David T. Smith
- Department of Chemistry & Biochemistry, University of Arizona, 1306 East University Boulevard, Tucson, Arizona 85721, United States
| | - Jon T. Njardarson
- Department of Chemistry & Biochemistry, University of Arizona, 1306 East University Boulevard, Tucson, Arizona 85721, United States
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Abstract
Parathyroid independent hypercalcemia is characterized by suppressed parathyroid hormone (PTH) in the presence of hypercalcemia. Well known causes and mechanisms are redistribution of calcium from the skeleton, by malignant diseases; inadequately increased intestinal calcium uptake mediated by increased vitamin D activity, and reduced renal elimination due to medications. Frequent and infrequent causes are discussed, and more recent mechanistic models presented in this review. Most hypercalcemic conditions are stable and in equilibrium between the different organs, whereas the utmost severe cases are characterized by rapid rising calcium levels and renal failure, resulting in a vicious circle where a disequilibrium state is developed. Management and treatment depends on the underlying condition and severity. The aim of this review is to discuss non-parathyroid hypercalcemic conditions as seen in the modern clinic, with a focus on areas where recent gain of knowledge has been achieved.
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Affiliation(s)
- Jens Bollerslev
- Section of Specialized Endocrinology, Division of Medicine, Oslo University Hospital, Norway; Faculty of Medicine, University in Oslo, Oslo, Norway.
| | - Mikkel Pretorius
- Section of Specialized Endocrinology, Division of Medicine, Oslo University Hospital, Norway; Faculty of Medicine, University in Oslo, Oslo, Norway
| | - Ansgar Heck
- Section of Specialized Endocrinology, Division of Medicine, Oslo University Hospital, Norway; Faculty of Medicine, University in Oslo, Oslo, Norway
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Messerli FH, Grodzicki T, Bangalore S, Rimoldi SF, Rexhaj E. When Guideline Authors Ignore Their Own Guidelines. Hypertension 2018; 72:e19. [DOI: 10.1161/hypertensionaha.118.11356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Franz H. Messerli
- From the Department of Cardiology, University of Bern, Switzerland (F.H.M., S.F.R., E.R.)
| | | | | | - Stefano F. Rimoldi
- From the Department of Cardiology, University of Bern, Switzerland (F.H.M., S.F.R., E.R.)
| | - Emrush Rexhaj
- From the Department of Cardiology, University of Bern, Switzerland (F.H.M., S.F.R., E.R.)
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Arroll B, Wallace H. Should we switch from bendrofluazide to chlorthalidone as the initial treatment for hypertension? A review of the available medication. J Prim Health Care 2018. [PMID: 29530222 DOI: 10.1071/hc16038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Thiazide diuretics are commonly prescribed in the treatment of hypertension. However, thiazide diuretics may not all be equal in their ability to reduce cardiovascular disease outcomes. AIM To determine if bendroflumethiazide/bendrofluazide, the most commonly used diuretic for hypertension in New Zealand, is as effective as other diuretics in terms of cardiovascular disease outcomes. METHODS Using recent reviews of thiazide-like (chlorthalidone or indapamide) and thiazide-type diuretics (hydrochlorothiazide and bendrofluazide) and a separate search of bendrofluazide, data on cardiovascular disease outcomes was extracted. RESULTS Nineteen relevant papers with 21 comparisons were found. All thiazide-based diuretics have been reported in at least one trial showing them to be more effective than placebo for cardiovascular disease outcomes, with the exception of chlorothiazide. There were no comparisons of bendrofluazide alone with other medications, but there were two studies with either bendrofluazide or hydrochlorothiazide compared with β-blockers; however, the pooled relative risk (RR) was not significant (RR = 1.10 (95% CI, 0.84-1.43)). For chlorthalidone, there were four comparisons with other medications, and the summary RR was statistically significant for cardiovascular disease outcomes (RR = 0.91 (95% CI, 0.85-0.98)). Chlorthalidone was significantly more effective for some cardiovascular disease outcomes when compared with doxazosin, amlodipine and lisinopril. CONCLUSIONS All thiazide-based medicines available in New Zealand are effective in terms of cardiovascular disease outcomes compared with placebo when used for treating hypertension, with the exception of chlorothiazide. Of the diuretics available in New Zealand for hypertension, only chlorthalidone has been shown to be more effective than other blood pressure-lowering medicines. It may be time to change from using bendrofluazide and start using chlorthalidone as a treatment for hypertension.
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Liang W, Ma H, Cao L, Yan W, Yang J. Comparison of thiazide-like diuretics versus thiazide-type diuretics: a meta-analysis. J Cell Mol Med 2017. [PMID: 28631393 PMCID: PMC5661252 DOI: 10.1111/jcmm.13205] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Thiazide diuretics are widely used for the management of hypertension. In recent years, it has been actively debated that there is interchangeability of thiazide‐type diuretics hydrochlorothiazide and thiazide‐like diuretics including indapamide and chlorthalidone for the treatment of hypertension. With the purpose of seeking out the best thiazide diuretic for clinicians, we summarized the existing evidence on the two types of drugs and conducted a meta‐analysis on their efficacy in lowering blood pressure and effects on blood electrolyte, glucose and total cholesterol. Twelve trials were identified: five based on the comparison of indapamide versus hydrochlorothiazide and seven based on the chlorthalidone versus hydrochlorothiazide. In the meta‐analysis of blood pressure reduction, thiazide‐like diuretics seemed to further reduce systolic BP ([95% CI]; −5.59 [−5.69, −5.49]; P < 0.001) and diastolic BP ([95% CI]; −1.98 [−3.29, −0.66]; P = 0.003). Meanwhile, in the analysis of side effects, the incidence of hypokalemia ([95% CI]; 1.58 [0.80, 3.12]; P = 0.19), hyponatremia ([95% CI]; −0.14 [−0.57, 0.30], P = 0.54), change of blood glucose ([95% CI];0.13 [−0.16, 0.41], P = 0.39) and total cholesterol ([95% CI]; 0.13 [−0.16, 0.41], P = 0.39) showed that there is no statistical significant differences between the two groups of drugs. In conclusion, using thiazide‐like diuretics is superior to thiazide‐type diuretics in reducing blood pressure without increasing the incidence of hypokalemia, hyponatraemia and any change of blood glucose and serum total cholesterol.
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Affiliation(s)
- Wenjing Liang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, and The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Hui Ma
- Department of Pediatrics and Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Luxi Cao
- Kidney Disease Center, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Wenjiang Yan
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, and The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Jingjing Yang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, and The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, Shandong, China
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Dhruva SS, Huang C, Spatz ES, Coppi AC, Warner F, Li SX, Lin H, Xu X, Furberg CD, Davis BR, Pressel SL, Coifman RR, Krumholz HM. Heterogeneity in Early Responses in ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial). Hypertension 2017; 70:94-102. [PMID: 28559399 DOI: 10.1161/hypertensionaha.117.09221] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 02/17/2017] [Accepted: 03/13/2017] [Indexed: 01/07/2023]
Abstract
Randomized trials of hypertension have seldom examined heterogeneity in response to treatments over time and the implications for cardiovascular outcomes. Understanding this heterogeneity, however, is a necessary step toward personalizing antihypertensive therapy. We applied trajectory-based modeling to data on 39 763 study participants of the ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) to identify distinct patterns of systolic blood pressure (SBP) response to randomized medications during the first 6 months of the trial. Two trajectory patterns were identified: immediate responders (85.5%), on average, had a decreasing SBP, whereas nonimmediate responders (14.5%), on average, had an initially increasing SBP followed by a decrease. Compared with those randomized to chlorthalidone, participants randomized to amlodipine (odds ratio, 1.20; 95% confidence interval [CI], 1.10-1.31), lisinopril (odds ratio, 1.88; 95% CI, 1.73-2.03), and doxazosin (odds ratio, 1.65; 95% CI, 1.52-1.78) had higher adjusted odds ratios associated with being a nonimmediate responder (versus immediate responder). After multivariable adjustment, nonimmediate responders had a higher hazard ratio of stroke (hazard ratio, 1.49; 95% CI, 1.21-1.84), combined cardiovascular disease (hazard ratio, 1.21; 95% CI, 1.11-1.31), and heart failure (hazard ratio, 1.48; 95% CI, 1.24-1.78) during follow-up between 6 months and 2 years. The SBP response trajectories provided superior discrimination for predicting downstream adverse cardiovascular events than classification based on difference in SBP between the first 2 measurements, SBP at 6 months, and average SBP during the first 6 months. Our findings demonstrate heterogeneity in response to antihypertensive therapies and show that chlorthalidone is associated with more favorable initial response than the other medications.
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Affiliation(s)
- Sanket S Dhruva
- From the Robert Wood Johnson Foundation Clinical Scholars Program (S.S.D., H.M.K.), Section of Cardiovascular Medicine (E.S.S., A.C.C., F.W., H.M.K.), Department of Internal Medicine, and Department of Obstetrics, Gynecology and Reproductive Sciences (X.X.), Yale School of Medicine, New Haven, CT; Department of Biostatistics (H.L.) and Section of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT; Department of Mathematics, Yale University, New Haven, CT (R.R.C.); The Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.H., E.S.S., A.C.C., F.W., S.-X.L., X.X., H.M.K.); Veterans Affairs Connecticut Healthcare System, West Haven (S.S.D.); Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); and University of Texas School of Public Health, Houston (B.R.D., S.L.P.)
| | - Chenxi Huang
- From the Robert Wood Johnson Foundation Clinical Scholars Program (S.S.D., H.M.K.), Section of Cardiovascular Medicine (E.S.S., A.C.C., F.W., H.M.K.), Department of Internal Medicine, and Department of Obstetrics, Gynecology and Reproductive Sciences (X.X.), Yale School of Medicine, New Haven, CT; Department of Biostatistics (H.L.) and Section of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT; Department of Mathematics, Yale University, New Haven, CT (R.R.C.); The Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.H., E.S.S., A.C.C., F.W., S.-X.L., X.X., H.M.K.); Veterans Affairs Connecticut Healthcare System, West Haven (S.S.D.); Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); and University of Texas School of Public Health, Houston (B.R.D., S.L.P.)
| | - Erica S Spatz
- From the Robert Wood Johnson Foundation Clinical Scholars Program (S.S.D., H.M.K.), Section of Cardiovascular Medicine (E.S.S., A.C.C., F.W., H.M.K.), Department of Internal Medicine, and Department of Obstetrics, Gynecology and Reproductive Sciences (X.X.), Yale School of Medicine, New Haven, CT; Department of Biostatistics (H.L.) and Section of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT; Department of Mathematics, Yale University, New Haven, CT (R.R.C.); The Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.H., E.S.S., A.C.C., F.W., S.-X.L., X.X., H.M.K.); Veterans Affairs Connecticut Healthcare System, West Haven (S.S.D.); Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); and University of Texas School of Public Health, Houston (B.R.D., S.L.P.)
| | - Andreas C Coppi
- From the Robert Wood Johnson Foundation Clinical Scholars Program (S.S.D., H.M.K.), Section of Cardiovascular Medicine (E.S.S., A.C.C., F.W., H.M.K.), Department of Internal Medicine, and Department of Obstetrics, Gynecology and Reproductive Sciences (X.X.), Yale School of Medicine, New Haven, CT; Department of Biostatistics (H.L.) and Section of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT; Department of Mathematics, Yale University, New Haven, CT (R.R.C.); The Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.H., E.S.S., A.C.C., F.W., S.-X.L., X.X., H.M.K.); Veterans Affairs Connecticut Healthcare System, West Haven (S.S.D.); Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); and University of Texas School of Public Health, Houston (B.R.D., S.L.P.)
| | - Frederick Warner
- From the Robert Wood Johnson Foundation Clinical Scholars Program (S.S.D., H.M.K.), Section of Cardiovascular Medicine (E.S.S., A.C.C., F.W., H.M.K.), Department of Internal Medicine, and Department of Obstetrics, Gynecology and Reproductive Sciences (X.X.), Yale School of Medicine, New Haven, CT; Department of Biostatistics (H.L.) and Section of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT; Department of Mathematics, Yale University, New Haven, CT (R.R.C.); The Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.H., E.S.S., A.C.C., F.W., S.-X.L., X.X., H.M.K.); Veterans Affairs Connecticut Healthcare System, West Haven (S.S.D.); Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); and University of Texas School of Public Health, Houston (B.R.D., S.L.P.)
| | - Shu-Xia Li
- From the Robert Wood Johnson Foundation Clinical Scholars Program (S.S.D., H.M.K.), Section of Cardiovascular Medicine (E.S.S., A.C.C., F.W., H.M.K.), Department of Internal Medicine, and Department of Obstetrics, Gynecology and Reproductive Sciences (X.X.), Yale School of Medicine, New Haven, CT; Department of Biostatistics (H.L.) and Section of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT; Department of Mathematics, Yale University, New Haven, CT (R.R.C.); The Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.H., E.S.S., A.C.C., F.W., S.-X.L., X.X., H.M.K.); Veterans Affairs Connecticut Healthcare System, West Haven (S.S.D.); Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); and University of Texas School of Public Health, Houston (B.R.D., S.L.P.)
| | - Haiqun Lin
- From the Robert Wood Johnson Foundation Clinical Scholars Program (S.S.D., H.M.K.), Section of Cardiovascular Medicine (E.S.S., A.C.C., F.W., H.M.K.), Department of Internal Medicine, and Department of Obstetrics, Gynecology and Reproductive Sciences (X.X.), Yale School of Medicine, New Haven, CT; Department of Biostatistics (H.L.) and Section of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT; Department of Mathematics, Yale University, New Haven, CT (R.R.C.); The Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.H., E.S.S., A.C.C., F.W., S.-X.L., X.X., H.M.K.); Veterans Affairs Connecticut Healthcare System, West Haven (S.S.D.); Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); and University of Texas School of Public Health, Houston (B.R.D., S.L.P.)
| | - Xiao Xu
- From the Robert Wood Johnson Foundation Clinical Scholars Program (S.S.D., H.M.K.), Section of Cardiovascular Medicine (E.S.S., A.C.C., F.W., H.M.K.), Department of Internal Medicine, and Department of Obstetrics, Gynecology and Reproductive Sciences (X.X.), Yale School of Medicine, New Haven, CT; Department of Biostatistics (H.L.) and Section of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT; Department of Mathematics, Yale University, New Haven, CT (R.R.C.); The Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.H., E.S.S., A.C.C., F.W., S.-X.L., X.X., H.M.K.); Veterans Affairs Connecticut Healthcare System, West Haven (S.S.D.); Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); and University of Texas School of Public Health, Houston (B.R.D., S.L.P.)
| | - Curt D Furberg
- From the Robert Wood Johnson Foundation Clinical Scholars Program (S.S.D., H.M.K.), Section of Cardiovascular Medicine (E.S.S., A.C.C., F.W., H.M.K.), Department of Internal Medicine, and Department of Obstetrics, Gynecology and Reproductive Sciences (X.X.), Yale School of Medicine, New Haven, CT; Department of Biostatistics (H.L.) and Section of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT; Department of Mathematics, Yale University, New Haven, CT (R.R.C.); The Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.H., E.S.S., A.C.C., F.W., S.-X.L., X.X., H.M.K.); Veterans Affairs Connecticut Healthcare System, West Haven (S.S.D.); Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); and University of Texas School of Public Health, Houston (B.R.D., S.L.P.)
| | - Barry R Davis
- From the Robert Wood Johnson Foundation Clinical Scholars Program (S.S.D., H.M.K.), Section of Cardiovascular Medicine (E.S.S., A.C.C., F.W., H.M.K.), Department of Internal Medicine, and Department of Obstetrics, Gynecology and Reproductive Sciences (X.X.), Yale School of Medicine, New Haven, CT; Department of Biostatistics (H.L.) and Section of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT; Department of Mathematics, Yale University, New Haven, CT (R.R.C.); The Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.H., E.S.S., A.C.C., F.W., S.-X.L., X.X., H.M.K.); Veterans Affairs Connecticut Healthcare System, West Haven (S.S.D.); Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); and University of Texas School of Public Health, Houston (B.R.D., S.L.P.)
| | - Sara L Pressel
- From the Robert Wood Johnson Foundation Clinical Scholars Program (S.S.D., H.M.K.), Section of Cardiovascular Medicine (E.S.S., A.C.C., F.W., H.M.K.), Department of Internal Medicine, and Department of Obstetrics, Gynecology and Reproductive Sciences (X.X.), Yale School of Medicine, New Haven, CT; Department of Biostatistics (H.L.) and Section of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT; Department of Mathematics, Yale University, New Haven, CT (R.R.C.); The Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.H., E.S.S., A.C.C., F.W., S.-X.L., X.X., H.M.K.); Veterans Affairs Connecticut Healthcare System, West Haven (S.S.D.); Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); and University of Texas School of Public Health, Houston (B.R.D., S.L.P.)
| | - Ronald R Coifman
- From the Robert Wood Johnson Foundation Clinical Scholars Program (S.S.D., H.M.K.), Section of Cardiovascular Medicine (E.S.S., A.C.C., F.W., H.M.K.), Department of Internal Medicine, and Department of Obstetrics, Gynecology and Reproductive Sciences (X.X.), Yale School of Medicine, New Haven, CT; Department of Biostatistics (H.L.) and Section of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT; Department of Mathematics, Yale University, New Haven, CT (R.R.C.); The Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.H., E.S.S., A.C.C., F.W., S.-X.L., X.X., H.M.K.); Veterans Affairs Connecticut Healthcare System, West Haven (S.S.D.); Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); and University of Texas School of Public Health, Houston (B.R.D., S.L.P.)
| | - Harlan M Krumholz
- From the Robert Wood Johnson Foundation Clinical Scholars Program (S.S.D., H.M.K.), Section of Cardiovascular Medicine (E.S.S., A.C.C., F.W., H.M.K.), Department of Internal Medicine, and Department of Obstetrics, Gynecology and Reproductive Sciences (X.X.), Yale School of Medicine, New Haven, CT; Department of Biostatistics (H.L.) and Section of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT; Department of Mathematics, Yale University, New Haven, CT (R.R.C.); The Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.H., E.S.S., A.C.C., F.W., S.-X.L., X.X., H.M.K.); Veterans Affairs Connecticut Healthcare System, West Haven (S.S.D.); Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); and University of Texas School of Public Health, Houston (B.R.D., S.L.P.).
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Ten Medication-Related Tips in Outpatient Practice. Am J Med 2017; 130:146-147. [PMID: 27746292 DOI: 10.1016/j.amjmed.2016.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 09/06/2016] [Accepted: 09/06/2016] [Indexed: 11/23/2022]
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Onnainty R, Schenfeld EM, Petiti JP, Longhi MR, Torres A, Quevedo MA, Granero GE. Permeability Profiles and Intestinal Toxicity Assessment of Hydrochlorothiazide and Its Inclusion Complex with β-Cyclodextrin Loaded into Chitosan Nanoparticles. Mol Pharm 2016; 13:3736-3746. [DOI: 10.1021/acs.molpharmaceut.6b00532] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- R. Onnainty
- Departamento de
Farmacia, UNITEFA, CONICET, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Córdoba, X5000HUA, Argentina
| | - E. M. Schenfeld
- Departamento de
Farmacia, UNITEFA, CONICET, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Córdoba, X5000HUA, Argentina
| | - J. P. Petiti
- Centro de Microscopía Electrónica, UNC, INICSA, CONICET, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Córdoba, X5000HUA, Argentina
| | - M. R. Longhi
- Departamento de
Farmacia, UNITEFA, CONICET, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Córdoba, X5000HUA, Argentina
| | - A. Torres
- Centro de Microscopía Electrónica, UNC, INICSA, CONICET, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Córdoba, X5000HUA, Argentina
| | - M. A. Quevedo
- Departamento de
Farmacia, UNITEFA, CONICET, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Córdoba, X5000HUA, Argentina
| | - G. E. Granero
- Departamento de
Farmacia, UNITEFA, CONICET, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Córdoba, X5000HUA, Argentina
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Griebeler ML, Kearns AE, Ryu E, Thapa P, Hathcock MA, Melton LJ, Wermers RA. Thiazide-Associated Hypercalcemia: Incidence and Association With Primary Hyperparathyroidism Over Two Decades. J Clin Endocrinol Metab 2016; 101:1166-73. [PMID: 26751196 PMCID: PMC4803175 DOI: 10.1210/jc.2015-3964] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
CONTEXT Thiazide diuretics, the antihypertensive agent prescribed most frequently worldwide, are commonly associated with hypercalcemia. However, the epidemiology and clinical features are poorly understood. OBJECTIVE To update the incidence of thiazide-associated hypercalcemia and clarify its clinical features. PATIENTS AND METHODS In a population-based descriptive study, Olmsted County, Minnesota, residents with thiazide-associated hypercalcemia were identified through the Rochester Epidemiology Project and the Mayo Clinic Laboratory Information System from 2002-2010 and were added to the historical cohort beginning in 1992. MAIN OUTCOME Incidence rates were adjusted to the 2010 United States white population. RESULTS Overall, 221 Olmsted County residents were identified with thiazide-associated hypercalcemia an average of 5.2 years after initiation of treatment. Subjects were older (mean age, 67 years) and primarily women (86.4%). The incidence of thiazide-associated hypercalcemia increased after 1997 and peaked in 2006 with an annual incidence of 20 per 100,000, compared to an overall rate of 12 per 100,000 in 1992-2010. Severe hypercalcemia was not observed in the cohort despite continuation of thiazide treatment in 62.4%. Of patients discontinuing thiazides, 71% continued to have hypercalcemia. Primary hyperparathyroidism was diagnosed in 53 patients (24%), including five patients who underwent parathyroidectomy without thiazide discontinuation. CONCLUSIONS Many patients with thiazide-associated hypercalcemia have underlying primary hyperparathyroidism. Additionally, a sharp rise in thiazide-associated hypercalcemia incidence began in 1998, paralleling the increase observed in primary hyperparathyroidism in this community. Case ascertainment bias from targeted osteoporosis screening is the most likely explanation.
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Affiliation(s)
- Marcio L Griebeler
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine (M.L.G., A.E.K., R.A.W.); and Divisions of Biomedical Statistics and Informatics (E.R., P.T., M.A.H.) and Epidemiology (L.J.M.), Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota 55905; and Sanford University of South Dakota Medical Center (M.L.G.), Sioux Falls, South Dakota 57117
| | - Ann E Kearns
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine (M.L.G., A.E.K., R.A.W.); and Divisions of Biomedical Statistics and Informatics (E.R., P.T., M.A.H.) and Epidemiology (L.J.M.), Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota 55905; and Sanford University of South Dakota Medical Center (M.L.G.), Sioux Falls, South Dakota 57117
| | - Euijung Ryu
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine (M.L.G., A.E.K., R.A.W.); and Divisions of Biomedical Statistics and Informatics (E.R., P.T., M.A.H.) and Epidemiology (L.J.M.), Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota 55905; and Sanford University of South Dakota Medical Center (M.L.G.), Sioux Falls, South Dakota 57117
| | - Prabin Thapa
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine (M.L.G., A.E.K., R.A.W.); and Divisions of Biomedical Statistics and Informatics (E.R., P.T., M.A.H.) and Epidemiology (L.J.M.), Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota 55905; and Sanford University of South Dakota Medical Center (M.L.G.), Sioux Falls, South Dakota 57117
| | - Matthew A Hathcock
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine (M.L.G., A.E.K., R.A.W.); and Divisions of Biomedical Statistics and Informatics (E.R., P.T., M.A.H.) and Epidemiology (L.J.M.), Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota 55905; and Sanford University of South Dakota Medical Center (M.L.G.), Sioux Falls, South Dakota 57117
| | - L Joseph Melton
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine (M.L.G., A.E.K., R.A.W.); and Divisions of Biomedical Statistics and Informatics (E.R., P.T., M.A.H.) and Epidemiology (L.J.M.), Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota 55905; and Sanford University of South Dakota Medical Center (M.L.G.), Sioux Falls, South Dakota 57117
| | - Robert A Wermers
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine (M.L.G., A.E.K., R.A.W.); and Divisions of Biomedical Statistics and Informatics (E.R., P.T., M.A.H.) and Epidemiology (L.J.M.), Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota 55905; and Sanford University of South Dakota Medical Center (M.L.G.), Sioux Falls, South Dakota 57117
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Brown MJ, Williams B, Morant SV, Webb DJ, Caulfield MJ, Cruickshank JK, Ford I, McInnes G, Sever P, Salsbury J, Mackenzie IS, Padmanabhan S, MacDonald TM. Effect of amiloride, or amiloride plus hydrochlorothiazide, versus hydrochlorothiazide on glucose tolerance and blood pressure (PATHWAY-3): a parallel-group, double-blind randomised phase 4 trial. Lancet Diabetes Endocrinol 2016; 4:136-47. [PMID: 26489809 PMCID: PMC4728199 DOI: 10.1016/s2213-8587(15)00377-0] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 09/14/2015] [Accepted: 09/22/2015] [Indexed: 11/14/2022]
Abstract
BACKGROUND Potassium depletion by thiazide diuretics is associated with a rise in blood glucose. We assessed whether addition or substitution of a potassium-sparing diuretic, amiloride, to treatment with a thiazide can prevent glucose intolerance and improve blood pressure control. METHODS We did a parallel-group, randomised, double-blind trial in 11 secondary and two primary care sites in the UK. Eligible patients were aged 18-80 years; had clinic systolic blood pressure of 140 mm Hg or higher and home systolic blood pressure of 130 mmHg or higher on permitted background drugs of angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, β blockers, calcium-channel blockers, or direct renin inhibitors (previously untreated patients were also eligible in specific circumstances); and had at least one component of the metabolic syndrome in addition to hypertension. Patients with known diabetes were excluded. Patients were randomly assigned (1:1:1) to 24 weeks of daily oral treatment with starting doses of 10 mg amiloride, 25 mg hydrochlorothiazide, or 5 mg amiloride plus 12·5 mg hydrochlorothiazide; all doses were doubled after 12 weeks. Random assignment was done via a central computer system. Both participants and investigators were masked to assignment. Our hierarchical primary endpoints, assessed on a modified intention-to-treat basis at 12 and 24 weeks, were the differences from baseline in blood glucose measured 2 h after a 75 g oral glucose tolerance test (OGTT), compared first between the hydrochlorothiazide and amiloride groups, and then between the hydrochlorothiazide and combination groups. A key secondary endpoint was change in home systolic blood pressure at 12 and 24 weeks. This trial is registered with ClinicalTrials.gov, number NCT00797862, and the MHRA, Eudract number 2009-010068-41, and is now complete. FINDINGS Between Nov 18, 2009, and Dec 15, 2014, 145 patients were randomly assigned to amiloride, 146 to hydrochlorothiazide, and 150 to the combination group. 132 participants in the amiloride group, 134 in the hydrochlorothiazide group, and 133 in the combination group were included in the modified intention-to-treat analysis. 2 h glucose concentrations after OGTT, averaged at 12 and 24 weeks, were significantly lower in the amiloride group than in the hydrochlorothiazide group (mean difference -0·55 mmol/L [95% CI -0·96 to -0·14]; p=0·0093) and in the combination group than in the hydrochlorothiazide group (-0·42 mmol/L [-0·84 to -0·004]; p=0·048). The mean reduction in home systolic blood pressure during 24 weeks did not differ significantly between the amiloride and hydrochlorothiazide groups, but the fall in blood pressure in the combination group was significantly greater than that in the hydrochlorothiazide group (p=0·0068). Hyperkalaemia was reported in seven (4·8%) patients in the amiloride group and three (2·3%) patients in the combination group; the highest recorded potassium concentration was 5·8 mmol/L in a patient in the amiloride group. 13 serious adverse events occurred but the frequency did not differ significantly between groups. INTERPRETATION The combination of amiloride with hydrochlorothiazide, at doses equipotent on blood pressure, prevents glucose intolerance and improves control of blood pressure compared with montherapy with either drug. These findings, together with previous data about morbidity and mortality for the combination, support first-line use of amiloride plus hydrochlorothiazide in hypertensive patients who need treatment with a diuretic. FUNDING British Heart Foundation and National Institute for Health Research.
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Affiliation(s)
- Morris J Brown
- Clinical Pharmacology Unit, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.
| | - Bryan Williams
- Institute of Cardiovascular Sciences, University College London, London, UK; National Institute for Health Research, University College London Hospitals Biomedical Research Centre, London, UK
| | - Steve V Morant
- Medicines Monitoring Unit, Medical Research Institute, University of Dundee, Dundee, Scotland, UK
| | - David J Webb
- Clinical Pharmacology Unit, University of Edinburgh, Centre for Cardiovascular Science, Queen's Medical Research Institute, Edinburgh, Scotland, UK
| | - Mark J Caulfield
- William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, Scotland, UK
| | - Gordon McInnes
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, UK
| | - Peter Sever
- International Centre for Circulatory Health, Imperial College London, London, UK
| | - Jackie Salsbury
- Clinical Pharmacology Unit, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Isla S Mackenzie
- Medicines Monitoring Unit, Medical Research Institute, University of Dundee, Dundee, Scotland, UK
| | - Sandosh Padmanabhan
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, UK
| | - Thomas M MacDonald
- Medicines Monitoring Unit, Medical Research Institute, University of Dundee, Dundee, Scotland, UK
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Efficacy of Low-Dose Chlorthalidone and Hydrochlorothiazide as Assessed by 24-h Ambulatory Blood Pressure Monitoring. J Am Coll Cardiol 2016; 67:379-389. [DOI: 10.1016/j.jacc.2015.10.083] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 10/23/2015] [Accepted: 10/27/2015] [Indexed: 12/31/2022]
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Argulian E, Grossman E, Messerli FH. Misconceptions and facts about treating hypertension. Am J Med 2015; 128:450-5. [PMID: 25486449 DOI: 10.1016/j.amjmed.2014.11.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 10/31/2014] [Accepted: 11/03/2014] [Indexed: 12/17/2022]
Abstract
Hypertension is a powerful risk factor strongly linked to adverse cardiovascular outcomes. Because of its high prevalence, health care providers at many levels are involved in treating hypertension. Distinct progress has been made in improving the rates of hypertension awareness and treatment over years, but the overall control of hypertension remains inadequate. Several recent guidelines from different sources have been put forward in an attempt to bridge the gap between existing evidence and clinical practice. Despite this effort, several misconceptions about treating hypertensive cardiovascular disease continue to persist among clinicians. This review highlights some of the misconceptions regarding antihypertensive therapy.
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Affiliation(s)
- Edgar Argulian
- Mt Sinai St Luke's and Roosevelt Hospitals, New York, NY.
| | - Ehud Grossman
- The Chaim Sheba Medical Center, Tel Hashomer, Israel
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Weber F, Anlauf M. Treatment resistant hypertension--investigation and conservative management. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 111:425-31. [PMID: 25008301 DOI: 10.3238/arztebl.2014.0425] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 04/07/2014] [Accepted: 04/07/2014] [Indexed: 01/25/2023]
Abstract
BACKGROUND The introduction of invasive treatments, some of which are irreversible, for the entity called treatment-resistant hypertension (TRH) creates the need for a comprehensive discussion of the diagnostic evaluation that TRH requires and the available options for its conservative treatment. METHOD The pertinent literature is selectively reviewed in the light of the authors' longstanding clinical experience. RESULTS Our review of the literature suggests that the high prevalence of TRH in Germany (ca. 20%) can be nearly halved with the aid of more thorough diagnostic evaluation. Such an evaluation should include a review of the patient's antihypertensive drugs (adherence, daily dosing, concomitant medication), investigation for other vascular changes that might affect blood pressure measurement, and exclusion of white-coat hypertension, sleep apnea syndrome, and secondary rather than essential hypertension. As there have been no randomized trials of treatment for TRH, the physician confronted with such cases must devise treatments on the basis of observational data and pathophysiological reasoning (volume status considering renin levels, sympathetic blockade, vasodilatation). Such measures can presumably lower the number of truly treatment-resistant cases still further. CONCLUSION To save patients from preventable harm, patients should undergo a thorough diagnostic evaluation and-under close monitoring for side effects-conservative pharmacological and nonpharmacological treatments should be deployed before any invasive treatment is performed.
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Affiliation(s)
- Franz Weber
- St Walburga Hospital, Meschede, Private Practice at the Medical Care Center, Dialysis Center, Cuxhaven
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McCarren M, Twedt EL, Mansuri FM, Nelson PR, Peek BT. Engineering practice variation through provider agreement: a cluster-randomized feasibility trial. Ther Clin Risk Manag 2014; 10:905-12. [PMID: 25414573 PMCID: PMC4218905 DOI: 10.2147/tcrm.s69878] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Purpose Minimal-risk randomized trials that can be embedded in practice could facilitate learning health-care systems. A cluster-randomized design was proposed to compare treatment strategies by assigning clusters (eg, providers) to “favor” a particular drug, with providers retaining autonomy for specific patients. Patient informed consent might be waived, broadening inclusion. However, it is not known if providers will adhere to the assignment or whether institutional review boards will waive consent. We evaluated the feasibility of this trial design. Subjects and methods Agreeable providers were randomized to “favor” either hydrochlorothiazide or chlorthalidone when starting patients on thiazide-type therapy for hypertension. The assignment applied when the provider had already decided to start a thiazide, and providers could deviate from the strategy as needed. Prescriptions were aggregated to produce a provider strategy-adherence rate. Results All four institutional review boards waived documentation of patient consent. Providers (n=18) followed their assigned strategy for most of their new thiazide prescriptions (n=138 patients). In the “favor hydrochlorothiazide” group, there was 99% adherence to that strategy. In the “favor chlorthalidone” group, chlorthalidone comprised 77% of new thiazide starts, up from 1% in the pre-study period. When the assigned strategy was followed, dosing in the recommended range was 48% for hydrochlorothiazide (25–50 mg/day) and 100% for chlorthalidone (12.5–25.0 mg/day). Providers were motivated to participate by a desire to contribute to a comparative effectiveness study. A study promotional mug, provider information letter, and interactions with the site investigator were identified as most helpful in reminding providers of their study drug strategy. Conclusion Providers prescribed according to an assigned drug-choice strategy most of the time for the purpose of a comparative effectiveness study. This simple design could facilitate research participation and behavior change in non-research clinicians. Waiver of patient consent can broaden the representation of patients, providers, and settings.
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Affiliation(s)
- Madeline McCarren
- Pharmacy Benefits Management Services, Department of Veterans Affairs, Hines, IL, USA
| | - Elaine L Twedt
- Pharmacy Benefits Management Services, Department of Veterans Affairs, Hines, IL, USA
| | | | | | - Brian T Peek
- Charles George VA Medical Center, Asheville, NC, USA
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Spinar J, Vitovec J, Soucek M. Anti-hypertensive strategies in patients with MEtabolic parameters, DIabetes mellitus and/or NephropAthy (the M E D I N A study). Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2014; 158:412-21. [DOI: 10.5507/bp.2013.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 07/02/2013] [Indexed: 11/23/2022] Open
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Chen S, Macaulay D, Swallow E, Diener M, Farooqui S, Xie J, Wu EQ. Real-world adherence and persistence associated with nebivolol or hydrochlorothiazide as add-on treatment for hypertension. Curr Med Res Opin 2014; 30:637-43. [PMID: 24255986 DOI: 10.1185/03007995.2013.864267] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare adherence and persistence associated with nebivolol and hydrochlorothiazide (HCTZ) as add-on hypertension treatments. RESEARCH DESIGN AND METHODS Adults with ≥1 hypertension diagnosis (ICD-9-CM 401-405) who used nebivolol or HCTZ as their first add-on antihypertensive therapy between 1/1/2008 and 9/30/2010 were identified from a large claims database. Patients had continuous enrollment for ≥1 year preceding (baseline period) and following (study period) the first qualifying prescription fill, and did not use nebivolol or HCTZ during the baseline period. A random sample of HCTZ patients meeting selection criteria were selected in a 3:1 ratio to nebivolol patients. MAIN OUTCOME MEASURES The probability of receiving each drug, adjusted for baseline patient demographics, significantly different comorbidities, and costs was estimated using a logistic model. Inverse propensity score weights were used to balance confounding factors for between-cohort comparisons. Adherence (estimated using the medication possession ratio [MPR]) and persistence (estimated as days from initiation to the first >30 day gap in the index drug supply) at 6, 9, and 12 months were compared using weighted t tests. RESULTS Baseline characteristics of nebivolol (n = 722) and HCTZ (n = 2166) patients were well balanced after weighting. At 12 months, nebivolol patients had a significantly higher MPR than HCTZ patients (0.76 vs. 0.70, P < 0.001), and medication persistence was 28 days longer (273 vs. 245 days, P < 0.001). Between-group differences were also significant at 6 and 9 months. CONCLUSIONS When used as an add-on therapy for hypertension, nebivolol was associated with significantly higher rates of adherence and persistence compared with HCTZ, after adjusting for baseline differences between treatment groups. These results may be impacted by limitations inherent in insurance claims data, such as the lack of clinical information.
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Tamargo J, Segura J, Ruilope LM. Diuretics in the treatment of hypertension. Part 1: thiazide and thiazide-like diuretics. Expert Opin Pharmacother 2014; 15:527-47. [DOI: 10.1517/14656566.2014.879118] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Zahedi K, Barone S, Xu J, Soleimani M. Potentiation of the effect of thiazide derivatives by carbonic anhydrase inhibitors: molecular mechanisms and potential clinical implications. PLoS One 2013; 8:e79327. [PMID: 24260196 PMCID: PMC3832474 DOI: 10.1371/journal.pone.0079327] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 09/29/2013] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Carbonic anhydrase inhibitors (CAI) are mild diuretics, hence not widely used in fluid overloaded states. They are however the treatment of choice for certain non-kidney conditions. Thiazides, specific inhibitors of Na-Cl cotransport (NCC), are mild agents and the most widely used diuretics in the world for control of mild hypertension. HYPOTHESIS In addition to inhibiting the salt reabsorption in the proximal tubule, CAIs down-regulate pendrin, therefore leaving NCC as the major salt absorbing transporter in the distal nephron, and hence allowing for massive diuresis by the inhibitors of NCC in the setting of increased delivery of salt from the proximal tubule. EXPERIMENTAL PROTOCOLS AND RESULTS Daily treatment of rats with acetazolamide (ACTZ), a known CAI, for 10 days caused mild diuresis whereas daily treatment with hydrochlorothiazide (HCTZ) for 4 days caused hardly any diuresis. However, treatment of rats that were pretreated with ACTZ for 6 days with a combination of ACTZ plus HCTZ for 4 additional days increased the urine output by greater than 2 fold (p<0.001, n = 5) compared to ACTZ-treated animals. Sodium excretion increased by 80% in the ACTZ plus HCTZ group and animals developed significant volume depletion, metabolic alkalosis and pre-renal failure. Molecular studies demonstrated ∼75% reduction in pendrin expression by ACTZ. The increased urine output in ACTZ/HCTZ treated rats was associated with a significant reduction in urine osmolality and reduced membrane localization of AQP-2 (aquaporin2). CONCLUSIONS These results indicate that ACTZ down-regulates pendrin expression and leaves NCC as the major salt absorbing transporter in the distal nephron in the setting of increased delivery of salt from the proximal tubule. Despite being considered mild agents individually, we propose that the combination of ACTZ and HCTZ is a powerful diuretic regimen.
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Affiliation(s)
- Kamyar Zahedi
- Center on Genetics of Transport and the Department of Medicine, University of Cincinnati, Research Services, Veterans Affairs Medical Center, Cincinnati, Ohio
| | - Sharon Barone
- Center on Genetics of Transport and the Department of Medicine, University of Cincinnati, Research Services, Veterans Affairs Medical Center, Cincinnati, Ohio
| | - Jie Xu
- Center on Genetics of Transport and the Department of Medicine, University of Cincinnati, Research Services, Veterans Affairs Medical Center, Cincinnati, Ohio
| | - Manoocher Soleimani
- Center on Genetics of Transport and the Department of Medicine, University of Cincinnati, Research Services, Veterans Affairs Medical Center, Cincinnati, Ohio
- * E-mail:
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Burnier M, Vuignier Y, Wuerzner G. State-of-the-art treatment of hypertension: established and new drugs. Eur Heart J 2013; 35:557-62. [DOI: 10.1093/eurheartj/eht465] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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26
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Ribeiro MCP, Ávila DS, Schiar VPP, Santos DBD, Meinerz DF, Duarte MMF, Monteiro R, Puntel R, de Bem AF, Hassan W, de Vargas Barbosa NB, Rocha JBT. Diphenyl diselenide supplementation reduces biochemical alterations associated with oxidative stress in rats fed with fructose and hydrochlorothiazide. Chem Biol Interact 2013; 204:191-9. [DOI: 10.1016/j.cbi.2013.05.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 04/27/2013] [Accepted: 05/14/2013] [Indexed: 02/07/2023]
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Trullàs JC, Morales-Rull JL, Formiga F. [Diuretic therapy in heart failure]. Med Clin (Barc) 2013; 142:163-70. [PMID: 23768854 DOI: 10.1016/j.medcli.2013.04.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 04/05/2013] [Accepted: 04/11/2013] [Indexed: 01/11/2023]
Abstract
Many of the primary clinical manifestations of heart failure (HF) are due to fluid retention, and treatments targeting congestion play a central role in HF management. Diuretic therapy remains the cornerstone of congestion treatment, and diuretics are prescribed to the majority of HF patients. Despite this ubiquitous use, there is limited evidence from prospective randomized studies to guide the use of diuretics. With the chronic use of diuretic and usually in advanced stages of HF, diuretics may fail to control salt and water retention. This review describes the mechanism of action of available diuretic classes, reviews their clinical use based on scientific evidence and discusses strategies to overcome diuretic resistance.
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Affiliation(s)
- Joan Carles Trullàs
- Servicio de Medicina Interna, Hospital Sant Jaume d'Olot, Universitat de Girona, Girona, España.
| | | | - Francesc Formiga
- Servicio de Medicina Interna, Hospital Universitari de Bellvitge-Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, España
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Angeli F, Verdecchia P, Pascucci C, Poltronieri C, Reboldi G. Pharmacokinetic evaluation and clinical utility of azilsartan medoxomil for the treatment of hypertension. Expert Opin Drug Metab Toxicol 2013; 9:379-85. [DOI: 10.1517/17425255.2013.769521] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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29
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Onnainty R, Schenfeld EM, Quevedo MA, Fernández MA, Longhi MR, Granero GE. Characterization of the Hydrochlorothiazide: β-Cyclodextrin Inclusion Complex. Experimental and Theoretical Methods. J Phys Chem B 2012; 117:206-17. [DOI: 10.1021/jp311274c] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Renée Onnainty
- Departamento de Farmacia, UNITEFA,
CONICET, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Córdoba, X5000HUA,
Argentina
| | - Esteban M. Schenfeld
- Departamento de Farmacia, UNITEFA,
CONICET, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Córdoba, X5000HUA,
Argentina
| | - Mario A. Quevedo
- Departamento de Farmacia, UNITEFA,
CONICET, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Córdoba, X5000HUA,
Argentina
| | - Mariana A. Fernández
- Departamento
de Química
Orgánica, INFIQC, CONICET, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Córdoba,
X5000HUA, Argentina
| | - Marcela R. Longhi
- Departamento de Farmacia, UNITEFA,
CONICET, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Córdoba, X5000HUA,
Argentina
| | - Gladys E. Granero
- Departamento de Farmacia, UNITEFA,
CONICET, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Córdoba, X5000HUA,
Argentina
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30
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Management of Hypertension in People with Diabetes Mellitus: Translating the 2012 Canadian Hypertension Education Program Recommendations into Practice. Can J Diabetes 2012. [DOI: 10.1016/j.jcjd.2012.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Kohlwes J. ACE inhibitors versus ARBs versus DRIs: a systematic update. J Gen Intern Med 2012; 27:1585; author reply 1586. [PMID: 22965670 PMCID: PMC3509292 DOI: 10.1007/s11606-012-2212-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Jeff Kohlwes
- Department of Medicine, Veterans Affairs Hospital, University of California, San Francisco, 4150 Clement St., San Francisco, CA 94121 USA
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32
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Joint statement of the European Association for the Study of Obesity and the European Society of Hypertension: obesity and difficult to treat arterial hypertension. J Hypertens 2012; 30:1047-55. [PMID: 22573071 DOI: 10.1097/hjh.0b013e3283537347] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Obese patients are prone to arterial hypertension, require more antihypertensive medications, and have an increased risk of treatment-resistant arterial hypertension. Obesity-induced neurohumoral activation appears to be involved. The association between obesity and hypertension shows large inter-individual variability, likely through genetic mechanisms. Obesity affects overall cardiovascular and metabolic risk; yet, the relationship between obesity and cardiovascular risk is complex and not sufficiently addressed in clinical guidelines. The epidemiological observation that obesity may be protective in patients with established cardiovascular disease is difficult to translate into clinical experience and practice. Weight loss is often recommended as a means to lower blood pressure. However, current hypertension guidelines do not provide evidence-based guidance on how to institute weight loss. In fact, weight loss influences on blood pressure may be overestimated. Nevertheless, weight loss through bariatric surgery appears to decrease cardiovascular risk in severely obese patients. Eventually, most obese hypertensive patients will require antihypertensive medications. Data from large-scale studies with hard clinical endpoints on antihypertensive medications specifically addressing obese patients are lacking and the morbidity from the growing population of severely obese patients is poorly recognized or addressed. Because of their broad spectrum of beneficial effects, renin-angiotensin system inhibitors are considered to be the most appropriate drugs for antihypertensive treatment of obese patients. Most obese hypertensive patients require two or more antihypertensive drugs. Finally, how to combine weight loss strategies and antihypertensive treatment to achieve an optimal clinical outcome is unresolved.
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Circelli M, Nicolini G, Egan CG, Cremonesi G. Efficacy and safety of delapril/indapamide compared to different ACE-inhibitor/hydrochlorothiazide combinations: a meta-analysis. Int J Gen Med 2012; 5:725-34. [PMID: 23049265 PMCID: PMC3459665 DOI: 10.2147/ijgm.s35220] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The main objective of this meta-analysis was to compare the efficacy of the combination of delapril and indapamide (D+I) to different angiotensin-converting enzyme inhibitor (ACEi) plus hydrochlorothiazide (HCTZ) combinations for the treatment of mild-to-moderate hypertension. A secondary objective was to examine the safety of these two combinations. Studies comparing the efficacy of D+I to ACEi+HCTZ combinations in hypertensive patients and published on computerized databases (1974–2010) were considered. Endpoints included percentage of normalized patients, of responders, change in diastolic and systolic blood pressure (DBP/SBP) at different time-points, percentage of adverse events (AEs), and percentage of withdrawal. Four head-to-head randomized controlled trials (D+I-treated, n = 643; ACEi+HCTZ-treated, n = 629) were included. Meta-analysis indicated that D+I-treated patients had a higher proportion with normalized blood pressure (P = 0.024) or responders (P = 0.002) compared to ACEi+HCTZ-treated patients. No difference was observed between treatments on absolute values of DBP and SBP at different time-points. Although the rate of patients reporting at least one AE was similar in both groups (10.4% versus 9.9%), events leading to study withdrawal were lower in the D+I group versus the ACEi+HCTZ group (2.3% versus 4.8%, respectively; P = 0.018). This meta-analysis suggests that treatment with D+I could provide a higher proportion of normalized or responder patients with good tolerability compared to ACEi+HCTZ combinations.
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Which diuretic is the preferred agent for treating essential hypertension: hydrochlorothiazide or chlorthalidone? Curr Cardiol Rep 2012; 14:673-7. [PMID: 22918623 DOI: 10.1007/s11886-012-0307-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Since their introduction over 50 years ago thiazide and thiazide-like diuretics have been a mainstay in the treatment of hypertension. Yet despite outcome evidence with chlorthalidone, the preponderance of usage has been with hydrochlorothiazide-either as monotherapy or in combination with other drugs. There is an increasing debate as to whether or not there are significant differences between hydrochlorothiazide and chlorthalidone. Early outcome studies, upon which the recommendations were made, utilized higher doses than those not only commonly employed in clinical practice, but also studied in more recent outcome trials. In addition, data suggests that chlorthalidone may be more potent, in equal doses, in its BP response than hydrochlorothiazide. A fundamental question asked in the debate is whether or not the benefits attributed to chlorthalidone as a thiazide-like diuretic may be reasonably ascribed to thiazides given differences in their pharmacokinetic properties and perhaps some other more recently noted differences.
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Current world literature. Curr Opin Nephrol Hypertens 2012; 21:557-66. [PMID: 22874470 DOI: 10.1097/mnh.0b013e3283574c3b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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36
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Should Two-Drug Initial Therapy for Hypertension Be Recommended for All Patients? Curr Hypertens Rep 2012; 14:324-32. [DOI: 10.1007/s11906-012-0280-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Jolobe OMP. A reappraisal of chlorthalidone also is required. Am J Med 2012; 125:e17; author reply e19. [PMID: 22624689 DOI: 10.1016/j.amjmed.2011.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Accepted: 10/07/2011] [Indexed: 10/28/2022]
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38
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Can selection bias in trials allow hydrochlorothiazide to be banned? Am J Med 2012; 125:e21; author reply e23. [PMID: 22624691 DOI: 10.1016/j.amjmed.2011.10.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Revised: 10/22/2011] [Accepted: 10/24/2011] [Indexed: 11/21/2022]
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Kurtz TW, Kajiya T. Differential pharmacology and benefit/risk of azilsartan compared to other sartans. Vasc Health Risk Manag 2012; 8:133-43. [PMID: 22399858 PMCID: PMC3295635 DOI: 10.2147/vhrm.s22595] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Azilsartan, an angiotensin II type 1 (AT1) receptor blocker (ARB), was recently approved by regulatory authorities for treatment of hypertension and is the 8th ARB to join the clinical market. This article discusses the medical reasons for introducing a new AT1 receptor blocker and reviews the experimental and clinical studies that have compared the functional properties of azilsartan to those of other ARBs. The main question addressed is: Does azilsartan have distinguishing features that should motivate choosing it over any of the other sartans for use in clinical practice? Based on studies conducted to date in hypertensive patients without serious comorbidities, azilsartan appears to be characterized by a superior ability to control 24-hour systolic blood pressure (BP) relative to other widely used ARBs including valsartan, olmesartan, and candesartan, and presumably others as well (eg, losartan). Compared to these other ARBs, azilsartan may increase the BP target control and response rate by an absolute value of 8%–10%. Greater antihypertensive effects of azilsartan might be due in part to its unusually potent and persistent ability to inhibit binding of angiotensin II to AT1 receptors. Preclinical studies have indicated that azilsartan may also have potentially beneficial effects on cellular mechanisms of cardiometabolic disease and insulin sensitizing activity that could involve more than just blockade of AT1 receptors and/or reduction in BP. However, the clinical relevance of these additional actions is unknown. Given that the general ability of antihypertensive drugs to protect against target organ damage is largely mediated by their ability to decrease BP, the enhanced antihypertensive effects of azilsartan should serve to justify clinical interest in this ARB relative to other molecules in the class that have a lower capacity to reduce BP.
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Affiliation(s)
- Theodore W Kurtz
- Department of Laboratory Medicine, University of California, San Francisco, CA 94107, USA.
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