All Thiazide‐Like Diuretics Are Not Chlorthalidone: Putting the ACCOMPLISH Study Into Perspective

Ernst, Michael E.; Carter, Barry L.; Basile, Jan

doi:10.1111/j.1751-7176.2008.00009.x

Cited by 37 publications

(20 citation statements)

References 37 publications

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“…New pharmaceutical preparations of CTDN, including scored 25-mg tablets and combinations with other common antihypertensives, would erase the practical advantage of HCTZ and would be more in accord with the best available evidence. These results support previous recommendations 7 that, in trials comparing medications with thiazide-like diuretics, the more appropriate comparator is CTDN. Finally, the inferiority of HCTZ cannot be explained entirely on the basis of HCTZ's lesser effect on OSBP.…”

Section: Perspectivessupporting

confidence: 90%

“…5,6 In the last several years, some have compared the drugs pharmacologically and have recommended CTDN rather than HCTZ. 3,[7][8][9][10][11][12] Two recent reanalyses of Multiple Risk Factor Intervention Trial (MRFIT) data have found CTDN to be superior to HCTZ in reducing cardiovascular events (CVEs) 13 and left ventricular hypertrophy. 14 However, no randomized, controlled trials have compared the 2 medications head to head with respect to CVEs.…”

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confidence: 99%

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Chlorthalidone Compared With Hydrochlorothiazide in Reducing Cardiovascular Events

2012

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Abstract-Hydrochlorothiazide (HCTZ) is widely used for hypertension, and prescriptions for HCTZ outnumber those for chlorthalidone (CTDN) by Ͼ20-fold in 2 recent surveys. Some have recently expressed a preference for CTDN. However, head-to-head trials testing the effect of the 2 drugs on cardiovascular events (CVEs) are lacking. We conducted a systematic review of randomized trials in which 1 arm was based on either HCTZ or CTDN followed by 2 types of network meta-analyses, a drug-adjusted analysis and an office systolic blood pressure-adjusted analysis. Nine trials were identified: 3 based on HCTZ and 6 based on CTDN. In the drug-adjusted analysis (nϭ50 946), the percentage of risk reduction in congestive heart failure for CTDN versus HCTZ was 23 (95% CI, 2-39; Pϭ0.032); and in all CVEs was 21 (95% CI, 12-28; PϽ0.0001). In the office systolic blood pressure-adjusted analysis (nϭ78 350), the percentage of risk reduction in CVEs for CTDN versus HCTZ was 18 (95% CI, Pϭ0.024). When the reduction in office systolic blood pressure was identical in the 2 arms, the risk for CVEs in HCTZ arms was 19% higher than in its nondiuretic comparator arms (Pϭ0.021). Relative to HCTZ, the number needed to treat with CTDN to prevent 1 CVE over 5 years was 27. In conclusion, CTDN is superior to HCTZ in preventing cardiovascular events. This cannot be attributed entirely to the lesser effect of HCTZ on office systolic blood pressure but may be attributed to the pleomorphic effects of alternative medications or to the short duration of action of HCTZ. Pharmaceutical preparations of the 2 drugs differ. HCTZ is available in 12.5-mg and 25.0-mg tablets and in 19 combination tablets, whereas CTDN is commonly available only in an unscored 25-mg tablet, an excessive dose in many patients, and in only 3 combination tablets, including atenolol, clonidine, and azilsartan. In light of the practical features of HCTZ, 2 there were 134 million prescriptions (solo or as a combination tablet) in 2007. 3 HCTZ is the 10th most commonly prescribed drug in the United States, with 48 million solo prescriptions annually from 2006 through 2010. 4 In 2 recent surveys, one in the United States and the other in Germany, HCTZ prescriptions outnumbered those for CTDN by Ͼ20-fold. 5,6 In the last several years, some have compared the drugs pharmacologically and have recommended CTDN rather than HCTZ. 3,[7][8][9][10][11][12] Two recent reanalyses of Multiple Risk Factor Intervention Trial (MRFIT) data have found CTDN to be superior to HCTZ in reducing cardiovascular events (CVEs) 13 and left ventricular hypertrophy. 14 However, no randomized, controlled trials have compared the 2 medications head to head with respect to CVEs. To examine whether 1 drug was superior over the other in reducing CVEs, we undertook a systematic review of randomized, controlled trials with either HCTZ or CTDN as the step 1 agent and then conducted 2 different types of network analyses. MethodsPreferred Reporting Items for Systematic Reviews and MetaAnalyses guidelines were followed th...

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Section: Perspectivessupporting

confidence: 90%

mentioning

confidence: 99%

Chlorthalidone Compared With Hydrochlorothiazide in Reducing Cardiovascular Events

2012

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“…rnst stated "the practitioner who bases decisions on evidence from randomized trials expecting to see similar benefits in practice should use the doses of antihypertensive drugs that were used in trials" (1). Although this statement seems intuitively obvious, it is commonly violated in the prescribing practices of thiazide diuretics when used for the treatment of hypertension or nephrolithiasis.…”

mentioning

confidence: 99%

“…Not only with respect to the dose used, but also with respect to the individual thiazide diuretic used. For example, despite the more compelling data in hypertension involving chlorthalidone use (1,2), hydrochlorothiazide (HCTZ) remains the most commonly prescribed antihypertensive medication in the United States (1). In the treatment of nephrolithiasis, it has been shown that thiazide and thiazide-like diuretics, especially HCTZ, are commonly not used in an evidence-based fashion (3).…”

mentioning

confidence: 99%

The Evidence-Based Use of Thiazide Diuretics in Hypertension and Nephrolithiasis

Reilly¹,

Peixoto²,

Desir³

2010

Clinical Journal of the American Society of Nephrology

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Thiazide-type diuretics are commonly used in the treatment of hypertension and nephrolithiasis. Evidence from randomized clinical trials needs to be considered in decisions about agent choice and dose. In nephrolithiasis, one of the major limitations of the literature is a paucity of data on the dose-response effect of hydrochlorothiazide (HCTZ) on urinary calcium excretion. The best available evidence for prevention of stone recurrence suggests the use of indapamide at 2.5 mg/d, chlorthalidone at 25 to 50 mg daily, or HCTZ 25 mg twice a day or 50 mg daily. In hypertension, chlorthalidone (12.5 to 30 mg daily) may be the best choice when a diuretic is used for initial therapy, with indapamide (1.5 mg daily) being a valuable alternative for older patients. When adding a thiazide to other drug classes, indapamide (2.5 mg daily) has demonstrated value in hypertensive patients who have had a stroke, and HCTZ (12.5 to 25 mg daily) has a safe track record in several patient groups. Although chlorthalidone has not been tested as add-on therapy, the authors believe it is a safe option in such cases.

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“…ACCOMPLISH has been criticized for its use of HCTZ rather than chlorthalidone, which is known to have superior BP lowering effects and was the thiazide used in most randomized trials. 24 Perhaps most importantly, chlorthalidone is superior to HCTZ for preventing cardiovascular events. 25 While this is a valid point, in the United States there is currently only one FDA-approved fixed-dose chlorthalidone/ARB combination drug (chlorthalidone/azilsartan).…”

Section: Combination Therapymentioning

confidence: 99%

Current and Future Treatment of Hypertension in the Sprint Era

Phillips

2015

Methodist DeBakey Cardiovascular Journal

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Based on the SPRINT trial, it is highly likely that new SPRINT-era guidelines will establish a blood pressure (BP) goal of < 130/80 mm Hg for those aged 50 or older who are at high risk for a cardiovascular event. In this group, SPRINT demonstrated that assignment to an intensive-treatment systolic BP (SBP) goal of < 120 mm Hg significantly reduced cardiovascular events and mortality compared to those assigned to a standard-treatment SPB goal of < 140 mm Hg. This review critically assesses current hypertension guidelines and presents predictions for SPRINT-era guidelines in the elderly, African Americans, and patients with uncomplicated essential hypertension, diabetes, chronic kidney disease, cardiovascular disease, and coronary artery disease. Specific attention is paid to BP goals and preferred pharmacological antihypertensive therapy in these populations, and an algorithm that incorporates the SPRINT trial results is presented. Inhibitors of the renin-angiotensin-aldosterone system as well as calcium channel blockers are universally accepted as first-line therapy in uncomplicated hypertension, but controversy exists over the role of thiazide diuretics and beta blockers. This review also discusses a physiologically and outcomes-based approach to combination therapy for treatment of hypertension.MDCVJ | XI (4) See Figure 1 Include ACE or ARB As a result, there was debate prior to SPRINT about the BP goal for those between the ages of 60 and 79. This was due to the evidence-based report from the panel members of JNC 8 (hereafter referred to as JNC-8P), who recommended a goal of < 140/90 mm Hg in those under 60 years of age and a more relaxed goal of < 150/90 mm Hg in those aged 60 years and older.3 The reaction to this recommendation was quite heated. Indeed, almost simultaneously with the publication of the guidelines in Although they agreed there was no hard outcome-based evidence (i.e., stroke, CV disease, or mortality) to support a BP goal of < 140/90 mm in those aged 60 years and older, they argued that relaxation of the guidelines would lead to undertreatment of those groups at high risk for complications of HTN, particularly African Americans. This position was supported by the Association of Black Cardiologists' Board of Directors, who also argued that since no harm could be proven by lowering BP to < 140/90 mm Hg in those aged 60 years and older, it was imprudent to raise the target to < 150/90 mm Hg. 16The debate over the past several years regarding treatment goals for those between the ages of 60 and 79 may have diverted attention from the larger issue: Despite decades of efforts and regardless of the goals, hypertension is still undertreated. A recent analysis demonstrated that there are 29.2 million adults in the United States between the ages of 60 and 79 whose SBP is higher than 150 mm Hg. 17 These individuals do not meet BP control levels in any current guideline. Hopefully the SPRINT results will stimulate renewed and reinvigorated efforts to achieve more intensive BP control.A subst...

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All Thiazide‐Like Diuretics Are Not Chlorthalidone: Putting the ACCOMPLISH Study Into Perspective

Cited by 37 publications

References 37 publications

Chlorthalidone Compared With Hydrochlorothiazide in Reducing Cardiovascular Events

Chlorthalidone Compared With Hydrochlorothiazide in Reducing Cardiovascular Events

The Evidence-Based Use of Thiazide Diuretics in Hypertension and Nephrolithiasis

Current and Future Treatment of Hypertension in the Sprint Era

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