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Interpretation of Blood Pressure in Epidemiological Studies and Clinical Trials
Published in Wilmer W Nichols, Michael F O'Rourke, Elazer R Edelman, Charalambos Vlachopoulos, McDonald's Blood Flow in Arteries, 2022
The modern era was revolutionized by the SHEP study, initiated by the U.S. NHLBI. SHEP established the importance of systolic blood pressure lowering in older patients with isolated systolic hypertension (ISH), with greatest reduction in stroke (reduced by 37 percent) and cardiac failure (reduced by 54 percent) and lesser (27 percent) reduction in myocardial infarction and coronary death. Active treatment was chlorthalidone (diuretic), with a β-blocker added if target blood pressure was not achieved. The comparator was placebo. SHEP’s results were decisive but led to another query: Were newer more expensive antihypertensive drugs, i.e. ACEIs, CCBs, α-blockers or ARBs, better than the older therapy with diuretics and β-blockers? The NHLBI ALLHAT trial was designed to answer this question and reported in late 2002. Findings (ALLHAT Collaborators, 2002) are consistent with the view that pressure reduction is all important and that the newer drugs (ACEIs, CCBs) have no special advantage for first-line treatment. Most ALLHAT patients did eventually require a cocktail of two or more drugs to achieve blood pressure control.
Idiopathic intracranial hypertension and CSF rhinorrhea
Published in Jyotirmay S. Hegde, Hemanth Vamanshankar, CSF Rhinorrhea, 2020
Hemanth Vamanshankar, Jyotirmay S Hegde
Malignant IIH is a variant of IIH presenting with rapidly progressive visual loss and papilledema. Prompt treatment with lumbar drain insertion, corticosteroids, and acetazolamide may be required prior to ONSD or a shunting procedure. IIH during pregnancy may be dealt with by serial lumbar punctures and headache management. Chlorthalidone may be preferred over acetazolamide. Surgery may be needed in rare circumstances, wherein an ONSD is preferred over shunting.2
Sodium Intake and Hypertension
Published in Austin E. Doyle, Frederick A. O. Mendelsohn, Trefor O. Morgan, Pharmacological and Therapeutic Aspects of Hypertension, 2020
T. O. Morgan, F. A. O. Mendelsohn, A. E. Doyle
Hypertensitivity reactions are the more serious side effects and are independent of dose. The other side effects are all dose dependent, and their incidence is reduced markedly if the dose of the thiazide is kept small. Doses of chlorothiazide of 500 mg daily or chlorthalidone of 25 mg daily have 70% of the antihypertensive action which can be achieved by larger doses, but have a lower incidence of complications. A dose of 2000 mg of chlorothiazide induces a maximal diuretic effect, but induces a much higher incidence of side effects than 500 mg. Further dose increases increase side effects with little extra therapeutic action (Figure 27).
Novel therapeutic approaches in the management of chronic kidney disease: a narrative review
Published in Postgraduate Medicine, 2023
Panagiotis Theofilis, Aikaterini Vordoni, Rigas G. Kalaitzidis
Diuretics have been a first-class antihypertensive agent since 1960. Their efficacy in the prevention of cardiovascular morbidity and mortality has been confirmed in longitudinal studies and meta-analyses. While loop diuretics are the main pharmacologic option in patients with advanced CKD (estimated GFR (eGFR)<30 ml/min/1.73 m2) [20], thiazide-like diuretics may be of importance. Chlorthalidone and indapamide have a longer duration of action compared to hydrochlorothiazide, with a similar safety profile [20]. In 2021, chlorthalidone was found to be effective in treating hypertensive patients with advanced CKD [21]. The response to chlorthalidone treatment could also be augmented in patients who are already on loop diuretics. Therefore, among patients with advanced CKD and receiving loop diuretics, initiation of chlorthalidone treatment at doses lower than 12.5 mg thrice weekly can be suggested [22]. It should be stated, however, that the use of chlorthalidone has been associated with hypokalemia, reversible increases in serum creatinine level, hyperglycemia, dizziness, and hyperuricemia in patients with advanced CKD [21].
Effectiveness of thiazide and thiazide-like diuretics in advanced chronic kidney disease: a systematic review and meta-analysis
Published in Renal Failure, 2023
Flávio Teles, Jorge Artur Peçanha de Miranda Coelho, Rosivânia Maria Albino, Fernanda Cristina Verçosa Pacheco, Evilly Rodrigues de Oliveira, Marcelo Augusto Duarte Silveira, Audes Diógenes M. Feitosa, Rodrigo Bezerra
Four studies evaluated variations in serum UA levels as an undesirable effect of thiazides. In all of the studies, an increase in UA was demonstrated, ranging from 1.0 to 2.2 mg/dL. Dussol et al. [17] demonstrated a nonsignificant increase (basal state 7.3 ± 2.2 mg/dL versus 9.5 ± 3.1 mg/dL after hydrochlorothiazide). In 2012, the same author found a significant increase in UA with hydrochlorothiazide (basal 7.1 ± 1.7 mg/dL versus 8.1 ± 2.1 mg/dL after treatment; p < 0.05). Agarwal et al. [18] demonstrated a significant increase in UA after 4 weeks of chlortalidone (mean increase of 1.64 mg/dL; p < 0.001). The same author observed hyperuricemia in 20% of patients treated with chlortalidone but only 2% with acute gout.
Managing the elderly patient with hypertension: current strategies, challenges, and considerations
Published in Expert Review of Cardiovascular Therapy, 2020
The patient should receive appropriate antihypertensive drugs for their comorbidities as discussed in this review. Drug treatment of resistant hypertension should maximize diuretic therapy [2,27] Excess sodium and fluid retention is an important cause of resistant hypertension [77–79]. Switching the patient from hydrochlorothiazide to a longer acting thiazide-type diuretic such as chlorthalidone may improve blood pressure control [27,80]. The beneficial effects of thiazide diuretics are reduced when the glomerular filtration rate is reduced to less than 40 ml/minute/1.73 m2 [2,27,78,81,82]. These patients should be treated with a loop diuretic such as furosemide every 12 h [2,27,81].