Place des diurétiques à faibles doses dans le traitement de l'hypertension artérielle

Author: Kaplan N.M.

Source: Disease Management & Health Outcomes, Volume 5, Special Issue 1, 1999 , pp. 11-20(10)

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Abstract:

The Place for Low Dose Diuretics in the Treatment of Hypertension

Improvements in the management of hypertension are clearly needed in view of the current evidence that only about one-fourth of patients with hypertension are being adequately treated. Specific guidelines recommended in the sixth report of the US Joint National Committee (JNC-VI) should help practitioners provide effective therapy to a much larger proportion of patients. These guidelines include the more widespread use of lifestyle modifications, including smoking cessation, moderate sodium restriction, weight loss and regular aerobic exercise. For those patients who are at relatively low overall risk of cardiovascular disease, such lifestyle modifications are recommended as sole therapy for 6 to 12 months, even if the blood pressure is as high as 160/100mm Hg.

On the other hand, immediate institution of antihypertensive drug therapy is recommended for those at relatively high risk even if blood pressure is as low as 130/85mm Hg. This includes all patients with diabetes, and those with renal insufficiency or congestive heart failure.

The initial choice of drug therapy should be based upon the absence or presence of certain compelling indications for specific drugs or a variety of comorbid conditions that favour certain drugs. On the basis of multiple randomised controlled trials, diuretics and, to a lesser degree, beta-blockers are recommended for those with uncomplicated hypertension. Diuretics are also preferred for elderly individuals with isolated systolic hypertension and are indicated for a variety of comorbid conditions, including heart failure, type 2 diabetes and osteoporosis.

On the basis of recent randomised controlled trials in the elderly, the dosage of diuretics should be kept low, equivalent to as little as 6.25mg of hydrochlorothiazide when given in combination with other agents, or 12.5 to 25mg when used alone. The biochemical alterations seen with higher doses of diuretics can thus be avoided, enabling the full cardioprotective effects to be provided.

The JNC-VI report further emphasises the need to add a diuretic to any other class of agent chosen as initial therapy if a full therapeutic response is not achieved. This need for a diuretic reflects in part the tendency for renal sodium retention when the blood pressure is lowered with non-diuretic agents. The addition of a low dose of diuretic will enhance the therapeutic efficacy of all other classes of drugs.

Lastly, JNC-VI emphasises the critical importance of using drugs that provide continued efficacy over the entire 24-hour period when given once daily. Compliance with therapy will thus be improved and protection provided against cardiovascular catastrophes that occur predominantly during the early morning hours.

Resume

Face a linsuffisance actuelle de la prise en charge de lhypertension arterielle qui se traduit par seulement un quart de patients correctement equilibres, lamelioration de cette situation est devenue une necessite. Les recommandations specifiques presentees dans le sixieme rapport du Joint National Committee (JNC-VI) aux Etats-Unis devraient conduire a une meilleure prise en charge dun plus grand nombre de patients atteints. Ces recommandations soulignent limportance des mesures hygieno-dietetiques notamment arret du tabagisme, restriction moderee de lapport sode, reduction de la surcharge ponderale et exercice physique regulier. Chez les patients qui presentent un risque global de maladies cardiovasculaires relativement faible, de telles modifications du mode de vie constituent le seul traitement recommande pendant 6 a 12 mois, meme si la pression arterielle atteint 160/100mm Hg.

En revanche, la mise en route rapide dun traitement pharmacologique antihypertenseur est recommande chez les patients presentant un risque relativement eleve, meme si la pression arterielle ne depasse pas 130/85mm Hg. Parmi ces patients figurent tous les sujets diabetiques, les insuffisants renaux ou ceux presentant une insuffisance cardiaque congestive.

Le choix initial dun traitement pharmacologique sera guide par la presence ou non dindications specifiques ou daffections concomitantes qui orienteront le choix vers certains types de medicaments. De nombreux essais controles randomises recommandent les diuretiques et, a un moindre degre, les beta-bloquants chez les sujets presentant une hypertension non compliquee. Les diuretiques constituent egalement un traitement de choix chez le sujet age presentant une hypertension systolique isolee et sont egalement indiques en cas daffections concomitantes, notamment insuffisance cardiaque, diabete de type 2 et osteoporose.

Les donnees fournies par des essais controles randomises chez le sujet age permettent de recommander lutilisation de diuretiques a faibles doses, equivalentes a 6,25mg dhydrochlorothiazide en cas dassociation a dautres medicaments ou a 12,5 a 25mg lors

Keywords: Reviews-on-treatment; Hypertension, treatment; Pharmacoeconomics; Diuretics, therapeutic-use; Beta-blockers, therapeutic-use; Prescribing; Practice-guideline

Language: French

Document Type: Review article

Affiliations: 1: Université du Texas, Southwestern Medical Center, Dallas, Etats-Unis *

Publication date: 1999-01-01

Place des diurétiques à faibles doses dans le traitement de l'hypertension artérielle

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