Diuretics: still essential drugs for the management of hypertension

According to most current international guidelines for hypertension, diuretics are indicated for elderly and black patients, unless they have any of a long list of other preferential indications. These recommendations are mostly based on the results of corporate-sponsored and biased trials, which have unsuccessfully tried to demonstrate the existence of pleiotropic effects of newer agents. Metaregression analyses have shown that the benefits of treatments are directly proportional to the difference in blood pressure between trial arms. New analyses of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack (ALLHAT) trial demonstrated the superiority of chlorthalidone over other agents in the prevention of end-stage renal disease in diabetics and of cardiovascular events in newer cases of diabetes. Despite this evidence, patients continue to withdraw from effective therapies in recent trials. The use of diuretics has also been challenged by the results of the Avoiding Cardiovascular Events in Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH) trial, which employed hydrochlorothiazide, a diuretic with lower potency and duration of action than chlorthalidone. Diuretics are still essential drugs for hypertension management, but diuretics with higher potency and duration of action, such as chlorthalidone, should be preferred.