Major study says for diabetics with high blood pressure diuretics are the best option

A major new study has found that for people with type 2 diabetes and high blood pressure, cheaper diuretic medications may be the most cost-effective option in reducing hypertension.

Lead author Dr. Paul K. Whelton, senior vice president for health sciences at Tulane University, says that diuretics are the optimal choice for initial therapy, as the newer and more expensive drugs do not perform any better at reducing heart attacks or death from heart disease.

Whelton says diuretics are the most appropriate first choice, not only for people who have no indication of diabetes, but for people with diabetes or prediabetes.

Whelton bases his finding on data collected as part of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), the largest clinical trial on high blood pressure ever conducted.

Whelton and his team collected data on more than 31,500 adults aged 55 and older, all had high blood pressure and at least one other condition putting them at risk for heart disease.

The study included over 13,100 people with type 2 diabetes, nearly 1,400 people with high blood sugar, pre-diabetes, and more than 17,000 people with normal blood sugar levels.

In the study the researchers compared the benefits of three drug types in controlling blood pressure in these individuals: a diuretic; another type of drug called a calcium channel blocker; and a third type, an angiotensin-converting enzyme inhibitor (ACE inhibitor).

The researchers found no significant difference between the drugs in controlling blood pressure in any group, when used as initial treatment, and based on that, Whelton believes that for most people with high blood pressure, the cheaper diuretics are the appropriate therapy for high blood pressure.

He does however caution that patients already taking an effective blood pressure medication should not make any sudden change to their therapy, without first talking to their doctor.

However, one expert, Stuart Weiss, an endocrinologist and clinical assistant professor of medicine at New York University School of Medicine, says the study does not really show anything that differentiates these drugs.

He cautions that despite the cost advantage of using diuretics, they might not be best for all patients, and new drugs not tested in ALLHAT might still be more effective for some diabetics.

He adds that most patients who are diabetic require multiple medications to control their blood pressure.

Weiss believes different medications work better for different patient types.

For people who consume too much salt, diuretics are a good initial treatment for high blood pressure. They also seem to work especially well for black patients.

He says for others, there are different first-line choices, and large studies should not clinically dictate the approach that individual physicians should take in treating their patients.

Weiss says other drugs, such as angiotensin II receptor blockers (ARB), may be more effective than any of the drugs tested in ALLHAT, and some studies show that by using Diovan, an ARB, in controlling blood pressure, there was a decrease in new-onset diabetes.

He personally prefers certain ACE inhibitors or an ARB as initial treatment, as those drugs have been shown, in large population-based studies, to delay the onset of diabetes and also to decrease insulin resistance as they lower blood pressure.

If Weiss finds that these drugs fail to lower blood pressure to a target level, he usually prescribes a diuretic.

The report appears in the June 27 issue of the Archives of Internal Medicine.

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