Antihypertensive treatment with diuretics: antediluvian or up to date?

Introduction: the decline of the thiazides Thiazide diuretics were among the first drugs able to lower blood pressure with minimal side-effects in a large proportion of the hypertensive population. In addition they appeared to potentiate nearly all other hypotensive drugs. Hence they were advised as the mainstay of antihypertensive treatment and were used in all large-scale trials 1 which showed beneficial effect of blood pressure lowering on cardiovascular morbidity and mortality. Despite this success story, the use of diuretics has rapidly declined during the past 15 years. From 1982 to 1988 prescription of diuretics in elderly hypertensives decreased from 59 to 33% in the USA, despite growing evidence of their benefits, particularly in this age group, during the same period 2. Most probably this trend persisted in all patient groups during the following years. As an extreme example, the last thiazide-type diuretic (chlorthalidone) was taken off the market in Turkey in 1992. Is this development justified, and if not (as is my personal opinion) what should be the place of diuretics today? Before discussing their relative drawbacks and merits, it is essential to review very briefly the reasons for their premature falling into disgrace.