β-blockers and diuretics: to use or not to use

Abstract

The present review scrutinizes the recommendations of many guidelines to use beta-blockers and diuretics as first-line therapy in hypertension. These recommendations were ostensibly based on multiple prospective randomized trials attesting to a reduction of morbidity and mortality with both beta-blockers and diuretics in monotherapy as well as in combination. Although diuretic-based therapy has been shown to prevent strokes (and, to a lesser extent, heart attacks, and cardiovascular and all-cause mortality), no such data are available for beta-blockers. To the contrary, a recent metaanalysis documented that although blood pressure was lowered significantly by beta-blockers, this drug class was ineffective in preventing coronary heart disease, and cardiovascular and all-cause mortality (odds ratio 1.01, 0.98, and 1.05, respectively). Patients who received a combination of beta-blockers and diuretics fared consistently worse than those taking diuretics alone. Although diuretics have an unparalleled track record of safety and efficacy, the recent findings suggesting that long-term use increased the risk for renal cell carcinoma (RCC) is of concern. Over the past decade, an association between RCC and diuretic therapy has been documented in nine case control studies (odds ratio 1.55, confidence interval [CI] 1.42-1.71). In three cohort studies, diuretic therapy was associated with a greater than twofold increased risk of RCC. The risk of RCC increased with cumulative diuretic doses. In the elderly, a low-dose diuretic probably remains a good choice for antihypertensive therapy; however, in middle-aged patients, particularly in women, diuretics should be avoided for the long-term treatment of hypertension. Sweeping recommendations for the use of beta-blockers and diuretics as preferred therapeutic strategies are inappropriate and a more sophisticated drug therapy regimen is often needed.

Combination therapy in hypertension: An update

“…Although β-blockers did have a beneficial effect on the BP, β-blocker therapy failed to favourably affect the cardiovascular events and mortality either alone or in combination with a diuretic [22]. Warmack reviewed and evaluated 5 placebo- controlled studies, 10 active-controlled studies and 11 meta-analyses for assessing the effects of β-blockers on cardiovascular and cerebrovascular outcomes in the treatment of hypertension.…”

Beyond the Usual Strategies for Blood Pressure Reduction: Therapeutic Considerations and Combination Therapies

“…The use of β blockers has achieved success in hypertension, particularly in patients with associated coronary artery disease. A meta‐analysis to evaluate the effects of treatment with β blockers in the elderly suggested that thiazides are superior to β blockers in this population in the control of blood pressure and reduction of the cardiovascular event rate 43 . However, this meta‐analysis has been questioned because the majority of patients received both diuretics and β blockers, and much of the difference between agents occurred in a single trial with a high drop‐out rate 44 .…”

“…A meta-analysis to evaluate the effects of treatment with β blockers in the elderly suggested that thiazides are superior to β blockers in this population in the control of blood pressure and reduction of the cardiovascular event rate. 43 However, this meta-analysis has been questioned because the majority of patients received both diuretics and β blockers, and much of the difference between agents occurred in a single trial with a high drop-out rate. 44 Although β blockers are still advocated by some as a suitable first-line therapy for elderly patients, 45 some experts would not use β blockers as monotherapy for the elderly hypertensive patient despite the fact that their use reduces strokes and congestive heart failure in this population.…”

The β Blockers: Are They as Protective in Hypertension as in other Cardiovascular Conditions?

“…For several years, the beneficial effects of β blockers for hypertension have come under intense scrutiny by a number of investigators. Messerli et al 16,17 examined 10 trials involving 16,164 elderly patients randomized to diuretics and/or β blockers. Diuretic therapy was found to be superior to β blockers in this patient population for controlling blood pressure and reducing cardiovascular events.…”