TO THE EDITOR: I read with great in...

TO THE EDITOR: I read with great interest the article, "New increases in the Management of Hypertension," (1) in American Family Physician, which provides an estimable introduction to the management of this condition.

I am aware of the guidelines onward offering diuretics as first-line therapy. However, I must take issue with the authors' assertion that diuretics should be the first or secondary drug administered for the have charge of of hypertension in patients who have diabetes. It has been lengthy established that diuretics, especially thiazide diuretics, adversely affect grape-sugar metabolism. Although lower doses of these medications have les of an adverse result many of these patients have more unadorned hypertension that requires maximal dosing of treatment strategies. (2) The use of this class of medications can worsen diabetic sugar control unnecessarily because other treatment options exist.

RICARDO C cowl M.D.

4201 Ellsworth Place

Gary, IN 46408

REFERENCES

(1) Magill MK Gunning K Saffel-Shrier s Gay C. New developments in the management of hypertension. Am Fam Physician 2003;68:853-8

(2) Vivian EM Rubinstein GB Pharmacologic management of diabetic nephropathy. Clin Ther 2002;24:1741-56

IN REPLY: Dr protection raises an excellent point regarding thiazide diuretics and house glucose control. This is an area of often controversy. The recommendations of the Joint National Committee in succession Prevention, Detection, Evaluation, and Treatment of High life-current Pressure (JNC 7) (1) and the American Diabetes Association (ADA) (2) advocate the use of thiazide diuretics (usually in addition to an angiotensin-converting enzyme [ACE] inhibitor) in patients who have hypertension and diabetes. The highest dosages of thiazide diuretics used in the 16 major clinical trials published since 1990 (on which these recommendations are based) were 25 mg of chlorthalidone or hydrochlorothiazide. (3) In a meta-analysis, (4) an average 1 percent elevation in house glucose levels was seen in patients taking thiazide diuretics at these dosages; this does not portray by action a clinically significant increase in mostly patients with diabetes. (4) Dosages above 25 mg appear to contribute barely to increases in adverse efficiencys such as hypokalemia, and not to further improvements in vital fluid pressure control. (4) The JNC and the ADA also advise that chiefly patients with diabetes will ne three or four medications to bring family pressures to the goal of les than 130/80 mm Hg with thiazide diuretics providing complementary reductions in life-blood pressure when combined with ACE inhibitors, angiotensin-receptor blocker and/or beta blocker (12) These statements do not support the use of the high or "maximal" dosages (50 mg or greater) of thiazide diuretics that have been associated with elevations in house glucose, but do support the use of lower doses in combination with other agents to reach vital fluid pressure goals. (3)

In terminuss of efficacy, thiazide diuretics have demonstrated the same or greater benefits onward long-term outcomes of cardiovascular and cerebrovascular disease in patients with diabetes as in those who do not have diabetes, reflecting the higher cardiovascular risk seen in patients with diabetes. (25) In the Antihypertensive and Lipid-Lowering Treatment to intercept Heart Attack Trial (ALLHAT), patients who had diabetes had fewer cardiovascular terminations with diuretic treatment than with ACE inhibitor treatment. (5) The mean increase in fasting grape-sugar levels in all patients through the whole extent of the four years of ALLHAT was 3 mg by dL (0.17 mmol per L) in those receiving chlorthalidone compared with a 06 mg by dL (0.03 mmol per L) increase in those receiving amlodipine, and a 14 mg by means of dL (0.08 mmol per L) decrease in those receiving lisinopril. Interestingly, among patients without diabetes at the beginning of the trial, the average fasting grape-sugar level in all treatment clusters was greater than 100 (1044 mg by means of dL [5.80 mmol per L] 1031 mg through dL [5.72 mmol per L] and 1005 mg by dL [5.58 mmol per L] respectively). These numbers suited the ADA criteria for the diagnosis of prediabetes, which is associated with adverse cardiovascular outcomes

With the existing dosages of thiazide diuretics being used in practice, the negative general intent of the small increases in line glucose levels is overshadowed on the beneficial effects seen in clinical trials using thiazides as part of the multidrug regimen that is required to achieve life-blood pressure control in most patients with diabetes.

KAREN GUNNING, PHARM.D.

CHRISTOPHER GAY, MD

MICHAEL K MAGILL, MD

University of Utah

375 Chipeta Way, Ste A

Salt Lake City, UT 84108

REFERENCES

(1) Chobanian AV, Bakris GL Black HR Cushman WC recent LA, Izzo JL Jr, et al. Seventh report of the Joint National Committee forward Prevention, Detection, Evaluation, and Treatment of High relations Pressure. Hypertension 2003;42:1206-52.

(2) American Diabetes Association. Standards of medical care in diabetes. Diabetes Care 2004;27:S15-35