Redefining diuretics use in hypertension: why select a thiazide-like diuretic?

Diuretic-induced hypokalaemia: an updated review

Diuretic-induced hypokalaemia is a common and potentially life-threatening adverse drug reaction in clinical practice. Previous studies revealed a prevalence of 7%-56% of hypokalaemia in patients taking thiazide diuretics. The clinical manifestations of hypokalaemia due to diuretics are non-specific, varying from asymptomatic to fatal arrhythmia. Diagnosis of hypokalaemia is based on the level of serum potassium. ECG is useful in identifying the more severe consequences. A high dosage of diuretics and concomitant use of other drugs that increase the risk of potassium depletion or cardiac arrhythmias can increase the risk of cardiovascular events and mortality. Thiazide-induced potassium depletion may cause dysglycaemia. The risk of thiazide-induced hypokalaemia is higher in women and in black people. Reducing diuretic dose and potassium supplementation are the most direct and effective therapies for hypokalaemia. Combining with a potassium-sparing diuretic or blocker of the renin-angiotensin system also reduces the risk of hypokalaemia. Lowering salt intake and increasing intake of vegetables and fruits help to reduce blood pressure as well as prevent hypokalaemia.

Antihypertensive Prescribing for Uncomplicated, Incident Hypertension: Opportunities for Cost Savings

Background

A range of first-line similarly effective medications ranging in price are recommended for treating uncomplicated hypertension. Considering drug costs alone, thiazides and thiazide-like diuretics are the most cost-efficient option. We determined incident prescribing of thiazides for newly diagnosed hypertension as first-line treatment in Alberta, factors that predicted receiving thiazides vs more costly medications, and how much could be saved if more patients were prescribed thiazides.

Methods

Using a retrospective cohort design, factors predicting receiving thiazides vs other agents were determined using mixed effects logistic regression. Cost savings were simulated by shifting patients from other antihypertensive medications to thiazides and calculating the difference.

Results

Within our cohort of 89,548 adults, only 12% received thiazides as first-line treatment whereas 44% received angiotensin converting enzyme inhibitors, 17% received angiotensin receptor blockers, 16% received calcium channel blockers, and 10% received β-blockers. Antihypertensive medications were typically prescribed by office-based, general practitioners (88%). Being male and receiving a prescription from a physician with ≥ 20 years of practice and a high clinical workload were associated with increased odds of receiving nonthiazides. In the extreme case that all patients received thiazides as their first prescription, spending would have been reduced by a maximum of 95% (CAD$1.8 million).

Conclusions

Only 12% of Albertan adults with incident, uncomplicated hypertension were prescribed thiazides as first-line treatment. With the opportunity for drug cost savings, future research should evaluate the risk of adverse events and side effects across the drug classes and whether the costs associated with managing those risks could offset the savings achieved through increased thiazide use.

Effectiveness of Perindopril/Indapamide Single-Pill Combination in Uncontrolled Patients with Hypertension: A Pooled Analysis of the FORTISSIMO, FORSAGE, ACES and PICASSO Observational Studies

INTRODUCTION

Our objective was to determine the effectiveness of a perindopril/indapamide (Per/Ind) single-pill combination (SPC) in a broad range of patient profiles, including subgroups with varying hypertension severity, age and cardiovascular risk profiles.

METHODS

Patient data from four large prospective observational studies (FORTISSIMO, FORSAGE, PICASSO, ACES) were pooled. In each study, patients already treated for hypertension were switched to Per/Ind 10/2.5 mg SPC and systolic and diastolic blood pressure (SBP/DBP) measured at the 1-month (M1) and 3-month (M3) visits. Study endpoints included change in SBP and DBP from baseline to M1 and M3 and the percentage of patients achieving BP control (SBP/DBP < 140/90 mmHg for patients without diabetes or < 140/85 mmHg for patients with diabetes).

RESULTS

A total of 16,763 patients were enrolled and received Per/Ind (94% received the full dose of 10/2.5). Mean patient age was 61.4 years (36% were ≥ 65 years old), 57% were women, and 16% had isolated systolic hypertension (ISH). Mean baseline office SBP/DBP was 162/94 mmHg, and mean duration of hypertension was 11 years. Cardiovascular risk factors and comorbid conditions were common in this population. Significant mean reductions in SBP (- 23 mmHg) and DBP (- 11 mmHg) were observed at M1 compared with baseline (P < 0.001), which were maintained at M3 (- 30 mmHg and - 14 mmHg, respectively). At M3, BP control was achieved by 70% of patients (78% for ISH). In patients with SBP ≥ 180 mmHg at baseline (grade III hypertension), the mean SBP/DBP decrease was - 51/- 20 mmHg and 53% achieved BP control. Per/Ind was well tolerated with an overall rate of adverse events of 1.3%, most frequently cough and dizziness at rates of 0.3% and 0.2%, respectively.

CONCLUSION

In this hypertensive population including difficult-to-control patient subgroups, switching to Per/Ind 10/2.5 mg SPC led to rapid and important reductions in BP. BP control was achieved in 70% of patients overall in an everyday practice context.

Thiazide and Thiazide-like Diuretics in the Treatment of Arterial Hypertension: are there Any Differences?

In the current clinical guidelines for arterial hypertension, diuretics are considered one of the first line antihypertensive drugs, which are equivalent in their effectiveness to other main pharmacological classes used in the treatment of this disease. To date, much attention is paid to both the antihypertensive potential of diuretics and their safety profile and ability to influence prognosis. In this regard, a rational approach to the consideration of the clinical and pharmacological properties of these drugs is the isolation of thiazide and thiazide-like drugs among them, which is reflected in international clinical guidelines. Among thiazide-like diuretics, indapamide occupies a special place, favorably distinguished by its antihypertensive properties, metabolic neutrality, as well as the ability to improve the prognosis and favorably influence hard endpoints in the form of mortality rates in patients with hypertension. A unique feature of indapamide is also the presence, in addition to the direct diuretic effect, pleiotropic properties, including, in particular, some antagonism towards calcium and beneficial effects on arteries. This drug has been studied in a large number of studies, including such "difficult" categories of patients as the elderly and patients with diabetes mellitus, where indapamide has proven its powerful target-organ protective potential and metabolic neutrality, distinguishing it among both thiazide-like and thiazide diuretics. Indapamide provides a comprehensive target-organ protection at the level of the heart, blood vessels, kidneys and brain. Based on this, it can be expected that the widespread use of this drug as part of a first-line combination antihypertensive therapy will not only achieve target blood pressure levet in most patients with hypertension, but also provide an improved prognosis and improve the quality and duration of their life.

Modern trends in diuretics development

Diuretics are the first-line therapy for widespread cardiovascular and non-cardiovascular diseases. Traditional diuretics are commonly prescribed for treatment in patients with hypertension, edema and heart failure, as well as with a number of kidney problems. They are diseases with high mortality, and the number of patients suffering from heart and kidney diseases is increasing year by year. The use of several classes of diuretics currently available for clinical use exhibits an overall favorable risk/benefit balance. However, they are not devoid of side effects. Hence, pharmaceutical researchers have been making efforts to develop new drugs with a better pharmacological profile. High-throughput screening, progress in protein structure analysis and modern methods of chemical modification have opened good possibilities for identification of new promising agents for preclinical and clinical testing. In this review, we provide an overview of the medicinal chemistry approaches toward the development of small molecule compounds showing diuretic activity that have been discovered over the past decade and are interesting drug candidates. We have discussed promising natriuretics/aquaretics/osmotic diuretics from such classes as: vasopressin receptor antagonists, SGLT2 inhibitors, urea transporters inhibitors, aquaporin antagonists, adenosine receptor antagonists, natriuretic peptide receptor agonists, ROMK inhibitors, WNK-SPAK inhibitors, and pendrin inhibitors.

Diuretics and risk of lower extremity amputation amongst patients with insulin-treated type 2 diabetes - exploring the mechanism of possible sodium glucose co-transporter 2 inhibitor induced risk of lower extremity amputations

AIMS AND BACKGROUND

Sodium-glucose cotransporter-2 (SGLT2) inhibitor has been linked to an increased risk of lower extremity amputation (LEA) in patients with Type 2 Diabetes (T2D) and is known to induce volume depletion through osmotic diuresis. We investigated the potential association between diuretics use and the LEA risk in insulin-treated T2D patients.

METHODS AND MATERIALS

A retrospective cohort study was conducted on 10,320 insulin-treated T2D patients within the UK population. Cox proportional hazard models were utilised to estimate LEA hazard ratios. Amputation risk was compared between a propensity score-matched cohort of diuretics users versus non-users over a 20-year period.

RESULTS

Among 10,320 subjects, 6454 (52.3%) were on diuretics. In the full cohort, diuretic-treated patients had significantly higher risk of LEA than the non-diuretic individuals (HR: 1.89; 95%CI: 1.34-2.68). When adjusting for possible confounding effects, a 2.3-fold higher risk of amputation was observed (aHR: 2.45; 95%CI: 1.63-3.69). In the matched cohort (n = 580), this association is marginally significant (HR: 3.33; 95%CI: 1.17-18.9; p = .029).

CONCLUSION

While diuretic use appeared to be associated with an increased risk of LEA among insulin-treated T2D patients, this association is marginally significant after controlling for confounding factors by cohort matching. These results suggest that volume depletion may be a factor in increasing the risk of LEA amongst high-risk T2D patients, but the strength of this association is weak when adjusted for all other risk factors. Thus, patient selection is crucial when determining the safe use of agents that induce volume depletion in high risk patients with T2D.

Management of patients with digestive diseases during the COVID-19 pandemic: Clinical Practice Guidelines by the Gastroenterological Scientific Society of Russia

The presented clinical practice guidelines of the Gastroenterological Scientific Society of Russia (GSSR), diagnostic, and therapeutic approaches for patients with digestive diseases during the COVID-19 pandemic. The guidelines were approved by the XXIII Congress of the GSSR and the 22nd International Slavonic-Baltic Scientific Forum “St. Petersburg — Gastro-2020 ON-LINE” (St. Petersburg, June 11, 2020).

Management of patients with comorbidity during novel coronavirus (COVID-19) pandemic. National Consensus Statement 2020

The pandemic of the novel coronavirus infection (COVID-19), caused by SARS‑CoV‑2, has become a challenge to healthcare systems in all countries of the world. Patients with comorbidity are the most vulnerable group with the high risk of adverse outcomes. The problem of managing these patients in context of a pandemic requires a comprehensive approach aimed both at the optimal management in self-isolated patients not visiting medical facilities, and management of comorbidities in patients with COVID-19. The presented consensus covers these two aspects of managing patients with cardiovascular disease, diabetes, chronic obstructive pulmonary disease, gastrointestinal disease, and also pay attention to the multiple organ complications of COVID-19.

Blood Pressure-Lowering Therapy

Extensive evidence demonstrates that lowering blood pressure can substantially reduce the risk of atherosclerotic cardiovascular disease and death.In light of the latest 2018 European Society of Cardiology/European Society of Hypertension Joint Guidelines, we summarize the current recommendations about lifestyle intervention strategies, pharmacotherapy, and device-based treatments for the management of arterial hypertension. Special attention is given to direct effects exerted by some antihypertensive drugs targeting vascular wall cell components that are involved in the pathogenesis of atherosclerosis.

Hyperuricemia Associated with Thiazide Diuretics in Hypertensive Adults

Introduction

Thiazide diuretics are essential first-line anti-hypertensive drugs which not only maintain blood pressure but also reduce stroke and congestive heart failure associated with morbidity and mortality in hypertensive patients. However, thiazide diuretics are associated with elevated serum uric acid (SUA) levels. This study aimed to evaluate the impact of thiazide diuretic use on their SUA levels among hypertensive individuals of Pakistan.

Methods

In this cross-sectional, prospective study, adult hypertensive patients were recruited. They were divided into two groups - thiazide diuretic group and non-thiazide group. Demographic characteristics, hypertension-related characteristics, and SUA levels were included. Data were then entered and analysed using SPSS for Windows version 22.0 (IBM Corp., Armonk, NY, USA).

Results

In the thiazide group, 24.5% were hyperuricemic as compared to 15.3% in the non-thiazide group (p=0.03). The overall mean SUA levels in the thiazide group were significantly higher than those in the non-thiazide group (5.9 ± 2.1 vs. 5.3 ± 2.7 mg/dL; p=0.02). Males in the thiazide group also showed a similar pattern (5.9 ± 2.3 vs. 5.1 ± 2.1 mg/dL; p=0.02); however, the differences were insignificant in females. Patients using thiazide diuretics for one to three years were more non-hyperuricemic than hyperuricemic (p=0.000). Among hyperuricemic patients, 36.5% were taking thiazides for three to four years and 46% were taking them for more than four years (p<0.05).

Conclusion

Hyperuricemia is a more common occurrence in thiazide diuretic users as compared to non-users. The overall sample, and men using thiazide diuretics, reported a higher mean SUA as compared to non-users. As the years of thiazide usage advanced, the number of hyperuricemic participants also significantly increased.