E-drug: Re: 1999 WHO-ISH hypertension guidelines
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Dear Peter,
In response to your message questionning La revue Prescrire's
recommendations on the choice of antihypertensive drugs in diabetic patients:
Captopril and atenolol have been tried in diabetic patients in the UKPDS
(1,2). Diabetic patients received either treatment in case of blood
pressure above 180/105 (with other drugs than ACE or betablockers), or
treatment with captopril or atenolol targetting a blood pressure under
150/85. Captopril and atenolol significantly reduced the incidences of
cerebrovascular events, cardiac failure, and deterioration of retinopathy
(there was no difference as regards the incidence of coronary events and
mortality). Atenolol and captopril did not differ in terms of morbidity and
incidence of hypoglycaemia. However, treatment withdrawal for adverse
events was less frequent and blood glucose level was better controlled on
captopril than on atenolol.
Data concerning diuretic treatment are less convincing. Only chlortalidone
was compared to placebo in a subgroup of diabetic patients in a trial
involving old hypertensive patients (3). This subgroup analysis was not
planned for in the protocol and concerns only patients above 60. Low doses
of chlortalidone significantly reduced the incidence of coronary events in
this subgroup. In addition the CAPP study showed a lower incidence of
cardiovasculare events on captopril than on conventionnal treatment (mainly
diuretics or betablockers) in the sub-group of diabetic patients (4).
In diabetic patients, available evidence does not justify the
recommendation to use a diuretic as first-choice treatment of hypertension.
La revue Prescrire's article has been published in French (medical French
should be easily understood) (5) and is being translated for a next issue
of Prescrire International (June 1999). We have arranged to make available
a limited number of copies of the (French) article to those interested.
Request to the following e-mail address: international@prescrire.org
References:
1- UK Prospective Diabetes Study Group "Tight blood pressure control and
risqk of macrovascular and microvascular complications in type 2 diabetes:
UKPDS 38" BMJ 1998;317:703-713.
2- UK Prospective Diabetes Study Group "Efficacy of atenolol and captopril
in reducing risk of macrovascular and micorvascular complictions in type 2
diabetes: UKPDS 39" BMJ 1998;317:713-720.
3- Curb et al. "Effect of diuretic-based antihypertensive treatment on
cardiovascular disease risk in older diabetic patients with isolated
systolic hypertension" JAMA 1996;276(23):1886-1892.
4- Hansson L et al. "Effect of angiotensine-converting-enzyme inhibition
compared with conventional therapy on cardiovascular morbidity and
mortality in hypertension: the Captopril Prevention Project (CAPP)
radomised trial" Lancet 1999;353:611-616.
5- "Les traitements antihypertenseurs" Rev Prescr 1999;19(194):288-296.
J�r�me Sclafer for La revue Prescrire
<jeromjet@easynet.fr>
La revue Prescrire - BP 459 - 75527 Paris Cedex 11 - France
Tel: +33 (0)1 4700 9445
Fax: +33 (0)1 4252 1582
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