The diuretic dilemma and the management of mild hypertension

Diuretics are presently used as antihypertensive medications as first-step monotherapy or in combination with adrenergic-inhibiting agents in the majority of hypertensive patients in the United States. A 30-year experience has demonstrated that blood pressure is lowered to as great or greater degree with diuretics than with many of the antihypertensive drugs presently available, including converting enzyme inhibitors, calcium entry blockers, beta- or alpha-adrenergic inhibitors, or centrally acting sympatholytic agents. Diuretics appear to be especially effective in the elderly and in black patients. All of the major hypertension clinical trials on which we base our decisions for treatment have employed diuretics as first-step therapy, with a reduction in morbidity and mortality. The debate concerning the long-term safety of diuretic therapy has focused on the United States Multiple Risk Factor Intervention Trial results and several papers suggesting that the lipid-raising or potassium-lowering properties of diuretics may produce adverse effects. Suggestions have been made that the use of other drugs without metabolic side effects may result in greater benefit with less risk, especially in the management of mild hypertension where the risk of the disease is not immediate or great. A review of the MRFIT and lipid data from long-term studies have failed to establish the "toxicity" of diuretic agents. In addition, recent studies have not confirmed previous observations that diuretic-induced hypokalemia increases ventricular ectopy or contributes to sudden death.(ABSTRACT TRUNCATED AT 250 WORDS)