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- in the ALLHAT study, the first-line use of a thiazide diuretic, an angiotensin-converting
enzyme (ACE) inhibitor, or a calcium-channel blocker (CCB) for hypertension was
similarly effective in reducing the risk of major cardiovascular (CV) events
CCBs were less effective in preventing heart failure than thiazide diuretics,
whereas development of diabetes (defined as fasting blood glucose levels [FGs]
above 6.9mmol/l) was more frequent with thiazide diuretics than with CCBs
post-hoc subgroup analysis considered non-diabetic patients in ALLHAT who were
randomised to initially receive chlortalidone (n=8,419), amlodipine (n=4,958),
or lisinopril (n=5,034) (2)
- after two years, mean FGs were raised in all
groups — by 0.47mmol/l, 0.31mmol/l and 0.19mmol/l, respectively
cases of incident diabetes, when defined by a 6.9mmol/l FG threshold, were detected
in the chlortalidone group - however, absolute differences between groups in incident
diabetes were small (chlortalidone 9.3%, amlodipine 7.2%, lisinopril 5.6%)
risk of developing diabetes was lower for lisinopril (odds ratio [OR] 0.55, 95%CI
0.43 to 0.70, P<0.001) or amlodipine (OR 0.73, 95%CI 0.58 to 0.91, P=0.008) compared
- was no significant association between FG changes
at two years and any of the study endpoints (death, CV disease or end-stage renal
disease), whether analysed for all treatments combined or for chortalidone alone
support the results from the 14-year follow-up of SHEP (3) and suggest that, even
if diabetes does occur during the treatment of hypertension with thiazide diuretics,
this does not create any greater cardiovascular risk
- possible that that
the raised FGs that occur with thiazide diuretics arise from mechanisms that are
different from those associated with diabetes in other circumstances (4)
diuretics or CCBs are considered by NICE as equal first-line choices for people
who are black (i.e. of African or Caribbean descent, not mixed race, Asian or
Chinese) or aged 55 years or older (5):
- NICE suggests that the choice
between thiazide diuretics and CCBs should be made by the clinician and patient,
using careful clinical judgement about the patient’s risk of adverse effects and
consideration of the patient’s preference
ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group.
Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting
enzyme inhibitor or calcium channel blocker vs. diuretic. JAMA 2002;288:2981–97
- Barzilay JI et al.. ALLHAT Collaborative Research Group. Fasting glucose
levels and incident diabetes mellitus in older nondiabetic adults randomized to
receive 3 different classes of antihypertensive treatment. Arch Intern Med 2006;166:2191–201.
JB et al. Long-term effect of diuretic-based therapy on fatal outcomes in subjects
with isolated systolic hypertension with and without diabetes. Am J Cardiol 2005;95:29–35.
Extra March 2007.
- MeReC Bulletin 2006;17:1–20.
Last reviewed 01/2018