Diuretics Best First-step for High BP in Diabetics

Diuretics are just as effective for lowering high blood pressure (BP) in people with type 2 diabetes as newer, and more expensive, types of drug, a study shows.

ALLHAT is the largest study to compare these three major classes of medications to treat high blood pressure. The study originally reported in 2002 that diuretics were more beneficial as initial treatment for high blood pressure for protecting against adverse cardiovascular outcomes. This latest analysis shows that even among diabetics and those with mildly elevated fasting glucose — a sign of pre-diabetes — the less costly diuretics are at least as effective, may be more beneficial for some people.
About 73 percent of adults with diabetes have high blood pressure — which in diabetic patients is defined as greater than or equal to 130/80 mm Hg — or use prescription medications for their hypertension. Both diabetes and high blood pressure are major risk factors for coronary heart disease, and when both are present, significantly increase the risk for developing heart and kidney diseases. High blood pressure can lead to congestive heart failure, a condition in which the heart is weakened and cannot pump enough blood throughout the body.

Dr. Paul K. Whelton of Tulane University Sciences Center wrote that, While angiotensin-converting enzyme (ACE) inhibitors have been recommended for patients with diabetes who have high blood pressure and kidney damage, the best first-line treatment for hypertension in diabetic patients with no kidney damage is less certain, and colleagues write in the Archives of Internal Medicine.

To investigate, the researchers analyzed results from 31,152 patients participating in the ALLHAT trial who had been randomly assigned to treatment with a thiazide type diuretic (chlorthalidone), a calcium channel blocker (amlodipine besylate), or an ACE inhibitor (lisinopril). Among the participants there were 13,101 patients with type 2 diabetes, 1,399 with impaired fasting glucose, and 17,012 with normal levels of glucose.

After an average follow-up of nearly 5 years, there was no difference among the three drug treatment groups in rates of fatal heart disease or nonfatal heart attack, the researchers found.

Some significant differences in other outcomes were seen; for example, fatal or nonfatal heart disease occurred 73 percent more often among subjects with impaired fasting glucose who were on the ACE inhibitor than those taking the diuretic.

Heart failure was more common among individuals with diabetes and those with normal blood glucose levels who taking the ACE inhibitor or the calcium channel blocker compared to those on the diuretic.

Compared with the ACE inhibitor and the calcium channel blocker, the diuretic was:

· More protective against congestive heart failure in patients both with and without diabetes (by about 1/6 compared with the ACE-inhibitor, and by about 1/3 compared with the calcium channel blocker).
· More effective in lowering systolic blood pressure — the measure of blood pressure when the heart beats — among those with and without diabetes.
· At least equally protective against fatal coronary heart disease or non-fatal heart attacks in people with diabetes, those with elevated fasting glucose, and non-diabetics.
· Equally protective against death from all causes, end-stage kidney disease, or cancer in people with diabetes, those with elevated fasting glucose, and non-diabetics.
· In Black study participants, more protective against stroke in people with and without diabetes (compared with the ACE-inhibitor).

“This study shows the advantage of diuretics for preventing congestive heart failure in most people with high blood pressure — regardless of diabetes status.

"The ALLHAT findings suggest that thiazide type diuretics should be strongly considered as first-step agents for therapy in patients with hypertension and type 2 diabetes or impaired fasting glucose," the researchers conclude.

"These agents are not only efficacious but have been evaluated in many trials and are the least expensive medications to prescribe," they add.
Archives of Internal Medicine, June 27, 2005.

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