Who really determines your patients' prescriptions?

Article Abstract:

There was a great deal of response to an article by Pollare and colleagues (New England Journal of Medicine, 1989;321:868-873) describing changes in cholesterol levels caused by hydrochlorothiazide (a diuretic used in the treatment of high blood pressure) compared with captopril, an angiotensin converting enzyme (ACE) inhibitor, also used to reduce high blood pressure. Although the findings were not new, they became front-page news in the New York Times, and articles appeared in over 200 other newspapers. The study even received national television coverage. The pharmaceutical company that markets the ACE inhibitor furnished 30-, 60-, and 90-second audio and video spots to radio and television stations around the country, and held a press conference set up by a public relations firm. New prescriptions for oral diuretics declined 13 percent in the four months following the publication of the article. This kind of pharmaceutical industry practice has not been challenged by major medical organizations. The diuretics work well, and are generally well-tolerated, easy to individualize to the patient, and inexpensive. Shorter-term, large-scale trials have failed to demonstrate a decrease in coronary artery disease, but longer-term studies have found a decrease in treated subjects when compared with less vigorously treated subjects. A meta-analytical treatment of 14 trials demonstrated a beneficial effect of diuretic treatment. However, meta-analysis, which is a statistical manipulation technique for combining results from different studies, is very controversial, and the results are not considered valid by all statisticians. New antihypertensive medications widen treatment choice, but none combine all the favorable characteristics of diuretics, including low cost. Also, the newer therapies have not been subjected to rigorous clinical trials to prove their claim that drugs without metabolic side effects lower heart-related illness and mortality better than thiazide diuretics and beta blockers. (Consumer Summary produced by Reliance Medical Information, Inc.)

Evaluation, Pharmaceutical industry, Marketing, Ethical aspects, Antihypertensive drugs, Antihypertensive agents, Journalism, Medical, Medical journalism, editorial, Pharmaceutical ethics

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Renin predicts diastolic blood pressure response to nonpharmacologic and pharmacologic therapy

Article Abstract:

Dietary management of high blood pressure may be more successful in patients with high renin activity. Renin is an enzyme involved in the regulation of body fluids, one of the factors that controls blood pressure. Out of 593 patients with mild hypertension between 30 and 65 years old, 201 continued their usual diet, 203 followed a weight-loss diet, and 189 followed a high potassium and low sodium diet. Patients in each of the groups were treated with either chlorthalidone (a diuretic), atenolol (a beta-blocker) or a placebo, an inactive substance. Atenolol caused a greater drop in blood pressure in patients with high renin activity, and chlorthalidone caused a greater drop in blood pressure in patients with low renin activity. The weight loss and low-sodium diets caused a greater drop in blood pressure in patients with high renin activity. The weight loss diet was more effective than the low-sodium diet in reducing blood pressure. Both diets increased the response to atenolol and chlorthalidone.

Care and treatment, Renin

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Why are physicians not prescribing diuretics more frequently in the management of hypertension?

Article Abstract:

Physicians should be prescribing diuretics more frequently for their hypertensive patients. Diuretics help eliminate excess water from the body. The use of diuretics has decreased since 1983 because physicians believe they have adverse effects and do not significantly reduce mortality rates from coronary heart disease. However, these beliefs are not supported by any evidence. In fact, diuretics cost about one-tenth as much as calcium channel blockers and may be just as effective as ACE inhibitors, beta blockers and calcium channel blockers in improving quality of life.

Diuretics

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