Back to thiazide-diuretics for hypertension: reflections after a decade of irrational prescribing

Recently several trials addressing this issue have been finalised, and they provide a convincing answer: the newer drugs are no better than the older ones. In the largest trial to date (ALLHAT), thiazide-type diuretic was found to offer advantages over newer drugs. The medical community should now be capable of reaching consensus, and recommend thiazides as the first line therapy for the treatment of hypertension. Prescribing physicians, cardiologists, drug companies and health authorities are all partly responsible for the years of irrational prescribing that we have witnessed.All stakeholders should now contribute in order to achieve what is clearly in the public's interest: implementing the use of thiazides in clinical practice.The debate over first choice drug for the treatment of hypertension has been intense for years. Opinions have mainly differed with regard to the role of calcium channel blockers, angiotensin converting enzyme inhibitors, α blockers, and more recently the angiotensin II receptor antagonists. These drugs have been shown to effectively lower blood pressure, but until recently their effectiveness with regards to matters of importance, namely health outcomes such as reduction in myocardial infarctions and strokes, had not been proven. In contrast, thiazide diuretics and β blockers have been tested in numerous clinical trials, and have been shown to reduce the risk of cardiovascular disease in people with hypertension.Hypertension is associated with an increased risk of stroke and coronary heart disease. A review of clinical trials from the 1960s, 70s and 80s showed that the use of thiazides and β blockers had a convincing effect on stroke prevention – the added risk associated with elevated blood pressure was markedly reduced with such treatment [1]. However, the drugs were not as effective at preventing coronary heart disease – although the risk went down, persons on treatment still had a significantly higher risk than persons without hyperten