Thiazide diuretics: Treatment of choice for high blood pressure?

5. January 2009 William Davis (14)
Thiazide diuretics are a popular first-line treatment for hypertension among the primary care set.

This practice became especially well-established with the 2002 publication of the ALLHAT Study (Major Outcomes in High-Risk Hypertensive Patients Randomized to Angiotensin-Converting Enzyme Inhibitor or Calcium Channel Blocker vs Diuretic:The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)).

ALLHAT showed that an inexpensive diuretic like chlorthalidone (a weak diuretic in the thiazide class, similar to hydrochlorothiazide) as first-line treatment for hypertension achieved equivalent reductions in cardiovascular events (cardiovasular death and heart attack) as non-thiazide antihypertensives, lisinopril (an ACE inhibitor) and amlodipine (a calcium channel blocker, better known as Norvasc).

After 7 years of treatment, there was 14% death or heart attack among all three groups--no difference.

This was interpreted to mean that inexpensive thiazide diuretics like chlorthalidone offer as much benefit as other blood pressure medications at reduced cost.

On the surface, that's great. Anything that detracts from the ubiquitous pharmaceutical industry propaganda of bigger, better, more expensive drugs to replace old, inexpensive, generic drugs is fine by me.

But you knew there'd be more to this issue! If we accept that thiazides are equivalent to other single-drug treatments for high blood pressure, what do we do with the following issues:

--Thiazides deplete body potassium-This effect can be profound. In fact, built into the ALLHAT mortality rate is an expected death rate from potassium depletion. When potassium in the body and blood go low, the heart becomes electrically unstable and dangerous rhythms develop.

--Thiazides deplete magnesium--Similar in implication to the potassium loss, magnesium loss also creates electrical instability in the heart, not to mention exaggeration of insulin resistance, rise in triglycerides, reduction in HDL.

--Thiazides reduce HDL cholesterol

--Thiazides increase triglycerides

--Thiazides increase small LDL particles--You know, the number one cause for heart disease in the U.S.

--Thiazides increase uric acid--Uric acid is increasingly looking like a coronary risk factor: The higher the uric acid blood level, the greater the risk for heart attack. Thiazides have long been known to increase uric acid, occasionally sufficient to trigger attacks of gout (uric acid crystals that precipitate in joints, like rock candy). (Fully detailed Special Report on uric acid coming this week on the Track Your Plaque website.)

What about the advice we commonly give people to hydrate themselves generously? Yet we give them diuretics? Which is it: More hydration or less hydration? You can't have both.

Do thiazides exert an apparent cardiovascular risk reduction in a society due to its flagrant sodium obsession?

Thus, there are a number of inconsistencies in the thinking surrounding thiazides. In my experience, I have seen more harm done than good using these agents. While I cannot fully reconcile the reported benefit seen in ALLHAT with what I see in real life, all too often I see people having to take another drug to make up for a side-effect of a thiazide diuretic (e.g., high-dose prescription potassium to replace lost potassium, allopurinol to reduce uric acid, etc.). I have seen many people get hospitalized, even suffer near-fatal or fatal events from extremely low potassium or magnesium levels.

My personal view: ALLHAT or no, avoid thiazide diuretics like the plague. Sure, it might save money on a population basis, but I suspect that the ALLHAT data are deeply misleading.

What's better than a thiazide, calcium blocker, or ACE inhibitor? How about vitamin D restoration, thyroid normalization, wheat elimination?
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Comments (14) -

  • Anonymous

    1/5/2009 6:29:00 PM |

    Does wheat elimination apply to rye and other grains, or only to wheat?

  • Jay

    1/5/2009 8:24:00 PM |

    I am curious, do some of the potassium sparing diuretics ( like Maxzide ) eliminate some of these blood chemistry changes (all of which are concerning) ?

    I have been using a similar product and find my side effects minimal compared to the previous lisinopril/verapromil combo that resulted in the same degree of lowering BP for me.

    Thanks

  • Jeff

    1/5/2009 9:18:00 PM |

    My mother is on this drug and I just happened to discuss it with her a week or so ago.  She claims no potassium issues and that she takes the lowest possible dose.  I sense it doesn't make sense for her to be on this.  Any suggestions?

  • Anonymous

    1/5/2009 9:45:00 PM |

    Dr, Davis, this is not directly related to this post, but I have a question about fish oil. Mine comes in a capsule form with soybean oil. Is it acceptable or should I look for another one which does not contain soybean oil.

    I also took my first pill of Niacin yesterday ( Just got report of high total cholesterol levels -230). I was up almost all night and was frazzled similar to what I would feel if I drank coffee at night. Is this due to niacin?

  • rabagley

    1/6/2009 6:40:00 AM |

    Anonymous,

    Dr. Davis isn't answering questions on the blog, but I'll try to sum up without too badly screwing up what he might say.

    Dr. Davis is particularly against wheat as a negative value food ingredient.  He has quoted primary research and various non-mainstream dietary experts who theorize that wheat contains addictive substances and contains still more substances that worsen multiple risk factors for metabolic syndrome (early diabetes), diabetes, heart disease, etc.  Basically: bad stuff.  Whole wheat is very little different from refined wheat in his view.

    Dr. Davis doesn't quite seem ready to throw out all grains, and does not have much to say about oats, rice, barley, rye, etc. one way or the other.  I suspect that this is simply because there isn't that much reporting on those grains and he isn't as confident that they're quite as bad.

    Now for my take on it (I am a software developer with no dietary or medical training): high carbohydrate foods are dangerous.  Don't even get into the fact that grains are a really bad idea.  Those foods with refined, fast digesting carbohydrates (sugars, simple starches, refined flour, etc.) are slightly more dangerous than "whole grain" or "high fiber" foods, but only slightly more dangerous.  They're all bad.  

    They're bad because our bodies are not used to a diet containing very many carbohydrates.  Our bodies have evolved to thrive on a diet containing mostly fat and a moderate amount of protein with a few carbs here and there.  We tamper with that preference and pay the price with the "diseases of civilization" (Diabetes, Heart Disease, etc.).

    Carbohydrates used to be a signal that either game was scarce and/or winter was approaching.  When we eat large quantities of carbohydrates (more than 15-20% of calories), our bodies start to pack calories away.  This storage response is a reaction triggered by insulin, which is itself triggered by the digested sugars moving from the gut to the bloodstream.  When we chronically eat large quantities of carbohydrates, our fat cells get packed tight and eventually can't pack away any more calories.  When this happens, the fat cells are said to be "insulin resistant", and when that happens, you're only a perceptive doctor's visit away from being classified as having Type 2 diabetes.

    And that's only one way that a high-carb, low-fat diet is bad for you.  That doesn't even begin to get into HDL cholesterol, lipid particle sizes, triglycerides (fructose is one of the worst sources of triglycerides in the diet, and triglycerides are one of the primary indicators of risk of heart disease) or anything else.

    I previously states that "grain" itself is a bad idea but didn't explain why.  It's simple evolution.  An apple tree gets a benefit when an animal comes by and eats an apple.  The seeds will go through the digestive tract and emerge unscathed in a pile of fertilizer some distance from the original tree.  The tree wins all around.  But what if you crack open the apple seeds and try to eat them?  Bad plan.  Apple seeds have about a dozen poisons in them, including potassium cyanide.  The plant does not get a benefit if you eat the whole ovary.  We eat the whole ovary of grains and pulses.  This is risky because we have to defuse all of those poisons or we risk damage from those that accumulate or have damage that accumulates.  Some of the defensive chemicals can be neutralized with cooking, some with fermenting, some with physical removal of layers, some with oxidation.  There's a decent chance that you can get them all and not eat any toxins, but I'm not convinced that we're doing it right with soy, wheat, rice, oats, rye, spelt, millet, etc.

    We just don't know enough to be certain.  And there's no real reason to take the risk.

    Read up for yourself.  "Good Calories, Bad Calories" is a fantastic recounting about the history of dietary policy and dietary science, eventually leading to some very interesting conclusions about what makes for a good calorie and a bad calorie.

  • Anna

    1/6/2009 5:02:00 PM |

    Anonymous-
    high total cholesterol levels -230

    But did you have any of the lipid fractions done, too?  High total cholesterol may mean nothing, but you won't know that unless you have more information.  

    An example,  my total cholesterol and LDL (by calculation, not direct measurement has risen a bit (higher than yours, I think it was 261 last time) over the past 10 years with improvements in my diet over the past 5 yrs (LC, no gluten/wheat, low sugar/fructose, minimal processed foods/more home prepared foods, many foods sources direct from the farm/ranch).  But my endocrinologist was fussing about my basic lipid panel results.

    BUT my HDL has also improved quite a bit (gone up 20+) and while my LDL is high according to the conventional wisdom, it is made up of the large fluffy pattern type, which ISN'T associated with CVD.  My total chol/HDL ratio is great.  My triglycerides are very low (they used to be high when I ate high carb/low fat).  AND, my first coronary calcium scan score, done a few weeks ago was 0, no sign of plaque, despite many years of undiagnosed hypothyroidism & impaired glucose tolerance (both treated/managed now), and current high consumption of grass-fed butter and other natural traditional animal fats, whole fat dairy, and 2-3 eggs every single day, plus Vit D supplementation ( my Vit D levels drop too low on sun exposure alone, despite living in So Cal).

    So, the total chol is essentially meaningless without a context.  You need to know the lipid subfractions (by direct measurement, not "calculation") so that the number and size can be assessed.  Many primary care docs just don't understand this and only order the basic panel (much cheaper) instead of a more informative VAP.  

    My husband on the other hand, has a not so great cholesterol lipid fraction profile (he's a long-time smoker, but now trying harder to quit), and his coronary calcium scan score wasn't so rosy.  He started niacin a couple months ago and hasn't had too many problems with the side effects (the flushing has occurred, but not too disruptively).  BUT, he started with a really low dose (50 mg) and gradually built up the amount, going to 2 x 50 mg, 3 x 50 mg, etc.  He's now at 3 x 100 mg daily with little or no side effects.   You might try gradually increasing the dose to see  if that helps.

  • Robert M.

    1/6/2009 8:05:00 PM |

    Anonymous:

    Wheat, barley, and rye all contain the same gluten protein that can cause an immune system reaction or allergy.  Oats are often contaminated, although wheat-free oats are available at specialty stores.

  • Anna

    1/6/2009 11:55:00 PM |

    Grains are not essential to a healthy diet, even if one appears to not suffer from eating them (appears being the significant word!).

    "Essential" applies to nutrients that must come from the diet because the body cannot make them.  There are essential amino acids and essential fatty acids, but no essential carbohydrates.  The body can make all the carbohydrates it needs from a nutrient-dense diet without grains.

  • puddle

    1/7/2009 9:36:00 PM |

    I'd also point out that the Thiazides are sulfa drugs.  Which luckily my pharmacist's computer was aware of, because my medical team sure wasn't.  And I have an anaphylactic shock reaction to sulfa.

  • David

    1/8/2009 9:00:00 PM |

    I agree that it's generally not a good idea to be on blood pressure meds, but I'm curious about what we should do about these drugs for someone who has already had a heart attack? My dad had high BP (over 145/90) before his heart attack, and the docs (two stents later) put him on an ACE inhibitor (Lisinopril) and beta-blocker (Lopressor). He's been exercising, taking vitamin D, cutting out the wheat, and pretty much doing all the normal TYP stuff, and his BP is down to 112/60, heart rate like 54 bpm. Is there any reason someone in his condition would still need to be on the meds? This is not just a personal question, but a general note of curiosity.

    Those med recommendations came from Dr. O'Keefe, the vitamin D researcher here in Kansas City, by the way. After reading his book, I didn't think he'd be such a pill pusher, but he was! He hadn't even looked at dad's chart and was already telling him he needed to up the dose of all his meds. According to O'Keefe (and I was standing right there when he said this) "The best three things you can do for your health right now: 1. Statins. 2. Vitamin D. 3. Fish oil. Don't worry about any of those other supplements [referring to things like magnesium, CoQ10, pomegranate, cocoa, etc]. The science is Simvastatin. The science is Lisinopril."

    Well, at least he was promoting the vitamin D and fish oil! Even at that, though, he didn't even look to see how much fish oil dad was taking, and he told him 1,000-2,000 IU of vitamin D was fine- without even having the blood work back yet! Grrrr.....

    Anyone know of a good cardiologist in the Kansas City area?

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    8/20/2009 10:17:32 AM |

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    11/18/2009 3:11:29 PM |

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    11/3/2010 6:18:48 PM |

    Thus, there are a number of inconsistencies in the thinking surrounding thiazides. In my experience, I have seen more harm done than good using these agents. While I cannot fully reconcile the reported benefit seen in ALLHAT with what I see in real life, all too often I see people having to take another drug to make up for a side-effect of a thiazide diuretic (e.g., high-dose prescription potassium to replace lost potassium, allopurinol to reduce uric acid, etc.). I have seen many people get hospitalized, even suffer near-fatal or fatal events from extremely low potassium or magnesium levels.

  • simvastatin side effects

    5/7/2011 1:44:30 PM |

    Thiazide increases uric acid thus increasing the risk of heart attacks. The higher the level of uric acid blood level, the more the risk of heart attacks. This is a great information.

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