Therapeutic and economic controversies in antihypertensive therapy

Diuretics are recommended for initial antihypertensive therapy because of their low cost and lack of subjective side effects. Unlike alpha- and beta-adrenergic agents, however, diuretics frequently induce metabolic abnormalities that necessitate supplemental therapy and increased monitoring of clinical laboratory tests. These factors increase the total cost of diuretic therapy, making it comparable to that of the alpha- or beta-adrenergic drugs. We show that the total yearly costs of therapy, exclusive of office visits, for patients treated with any of these three classes of agents is approximately $175 to $250, regardless of the drug used. Diuretics are cost effective only in patients who do not require laboratory follow-up or supplemental therapy. Thus, the choice of a drug for initial therapy of hypertension may be based more appropriately on medical (particularly side effects and metabolic abnormalities) rather than financial considerations.