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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.
Hypertension
Published in Jahangir Moini, Matthew Adams, Anthony LoGalbo, Complications of Diabetes Mellitus, 2022
Jahangir Moini, Matthew Adams, Anthony LoGalbo
Medications are indicated because of BP level and whether atherosclerotic cardiovascular disease (ASCVD) or its risk factors exist. Diabetes mellitus and kidney disease are part of the ASCVD risk assessment. The patient must be continually reassessed. If still not at target BP, patient adherence must be improved before any drug is added, or another drug replaces a previous one. Initial medications often are ACE inhibitors, angiotensin II receptor blockers (ARBs), calcium channel blockers, or thiazide-type diuretics such as chlorthalidone or indapamide. However, for African American patients, with or without diabetes mellitus, calcium channel blockers or thiazide-type diuretics are first recommended, unless there is stage 3 or higher chronic kidney disease. If this is present, the ACE inhibitors or ARBs are used first. If two drugs are given initially, there are single-pill combinations with an ACE inhibitor or ARB, plus a diuretic or calcium channel blocker.
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
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].
Assessment of a strategy combining ambulatory blood pressure, adherence monitoring and a standardised triple therapy in resistant hypertension
Published in Blood Pressure, 2021
Erietta Polychronopoulou, Michel Burnier, Georg Ehret, Renate Schoenenberger-Berzins, Maxime Berney, Belen Ponte, Paul Erne, Murielle Bochud, Antoinette Pechère-Bertschi, Gregoire Wuerzner
The original component of our assessment strategy is the use of standard triple therapy based on a single pill combination of a calcium channel blocker and an angiotensin receptor blocker, and a thiazide-like diuretic. The three drugs used in our protocol had a very long half-life (olmesartan, amlodipine and chlorthalidone) limiting the clinical impact of missed doses [35,36]. The choice of chlorthalidone has been based on recent analyses suggesting the superiority of chlorthalidone over hydrochlorothiazide in lowering BP and preventing cardiovascular events [37,38]. This approach differs from most previously published strategies, in which the initially prescribed drugs are maintained and monitored. However, it follows current treatment guidelines suggesting to simplify the therapeutic regimen in all patients [1] and avoid dealing with under-dosed therapies, another frequent observation in patients with resistant hypertension [2]. In our hands, using a standard triple therapy, which has been reported to control BP in almost 80% of hypertensive patients [39], resulted in a slight increase in the percentage of patients achieving BP targets without noticeable side effects. Only 6.6% of patients refused to change their drug therapy.
Established and recent developments in the pharmacological management of urolithiasis: an overview of the current treatment armamentarium
Published in Expert Opinion on Pharmacotherapy, 2020
Mohamed Abou Chakra, Athanasios E. Dellis, Athanasios G. Papatsoris, Mohamad Moussa
There is a lack of data regarding adverse, long-term side effects of thiazides used for kidney stone prevention. However, the side effect profile of thiazide diuretics has been well studied in the setting of hypertension. Thiazide‐related side effects are more common with longer‐acting compounds, such as chlorthalidone and metolazone. Among the thiazide‐type diuretics, indapamide has the least significant metabolic derangements. Side effects may include hypokalemia, hypomagnesemia and hyperuricemia [54]. A large, prospective, cohort study (12,550 non diabetic adults [45‐ to 64‐ years old] who did not have diabetes concluded that subjects with hypertension who were taking thiazide diuretics were not at greater risk for the subsequent development of diabetes [55]. Adverse effects of thiazide and thiazide‐like diuretics on male sexual function are decreased libido, erectile dysfunction, and difficult ejaculation [56,57]. In addition, hydrochlorothiazide can cause photosensitivity [58]. There is a lack of data on the metabolic effects of thiazides used to prevent recurrent calcium nephrolithiasis. It remains unclear if metabolic effects occur and increase the risk of cardiovascular disease in otherwise healthy patients with recurrent nephrolithiasis on thiazide prophylaxis [59]. Thiazide prescription is associated with decreased urinary citrate, this is caused by thiazide‐induced hypokalemia, which would stimulate citrate reabsorption in the proximal tubules [60,61].