Journal of Primary Health Care Journal of Primary Health Care Society
Journal of The Royal New Zealand College of General Practitioners
RESEARCH ARTICLE (Open Access)

Should we switch from bendrofluazide to chlorthalidone as the initial treatment for hypertension? A review of the available medication

Bruce Arroll 1 , Henry Wallace 1
+ Author Affiliations
- Author Affiliations

1 Department of General Practice and Primary Health Care, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand

Correspondence to: Bruce Arroll, Department of General Practice and Primary Health Care, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. Email: bruce.arroll@auckland.ac.nz

Journal of Primary Health Care 9(2) 105-113 https://doi.org/10.1071/HC16038
Published: 9 June 2017

Journal Compilation © Royal New Zealand College of General Practitioners 2017.
This is an open access article licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Abstract

INTRODUCTION: Thiazide diuretics are commonly prescribed in the treatment of hypertension. However, thiazide diuretics may not all be equal in their ability to reduce cardiovascular disease outcomes.

AIM: To determine if bendroflumethiazide/bendrofluazide, the most commonly used diuretic for hypertension in New Zealand, is as effective as other diuretics in terms of cardiovascular disease outcomes.

METHODS: Using recent reviews of thiazide-like (chlorthalidone or indapamide) and thiazide-type diuretics (hydrochlorothiazide and bendrofluazide) and a separate search of bendrofluazide, data on cardiovascular disease outcomes was extracted.

RESULTS: Nineteen relevant papers with 21 comparisons were found. All thiazide-based diuretics have been reported in at least one trial showing them to be more effective than placebo for cardiovascular disease outcomes, with the exception of chlorothiazide. There were no comparisons of bendrofluazide alone with other medications, but there were two studies with either bendrofluazide or hydrochlorothiazide compared with β-blockers; however, the pooled relative risk (RR) was not significant (RR = 1.10 (95% CI, 0.84–1.43)). For chlorthalidone, there were four comparisons with other medications, and the summary RR was statistically significant for cardiovascular disease outcomes (RR = 0.91 (95% CI, 0.85–0.98)). Chlorthalidone was significantly more effective for some cardiovascular disease outcomes when compared with doxazosin, amlodipine and lisinopril.

CONCLUSIONS: All thiazide-based medicines available in New Zealand are effective in terms of cardiovascular disease outcomes compared with placebo when used for treating hypertension, with the exception of chlorothiazide. Of the diuretics available in New Zealand for hypertension, only chlorthalidone has been shown to be more effective than other blood pressure-lowering medicines. It may be time to change from using bendrofluazide and start using chlorthalidone as a treatment for hypertension.

KEYWORDS: Thiazides; diuretics; hypertension; cardiovascular diseases


References

[1]  Britten N. Time to talk about prescriptions. Prescriber. 1999; 10 13–4.

[2]  Best Practice Advocacy Centre New Zealand Which antihypertensive? Best Practice Journal. 2010; 31 14–32.

[3]  Chen P, Chaugai S, Zhao F, et al. Cardioprotective effect of thiazide-like diuretics: a meta-analysis. Am J Hypertens. 2015; 28 1453–63.
Cardioprotective effect of thiazide-like diuretics: a meta-analysis.CrossRef |

[4]  Olde Engberink RH, Frenkel WJ, van den Bogaard B, et al. Effects of thiazide-type and thiazide-like diuretics on cardiovascular events and mortality systematic review and meta-analysis. Hypertension. 2015; 65 1033–40.
Effects of thiazide-type and thiazide-like diuretics on cardiovascular events and mortality systematic review and meta-analysis.CrossRef | 1:CAS:528:DC%2BC2MXosFGgt7g%3D&md5=d2093ef618cd2f3005626b9214d7f6aaCAS |

[5]  Musini VM, Nazer M, Bassett K, et al. Blood pressure-lowering efficacy of monotherapy with thiazide diuretics for primary hypertension. Cochrane Database Syst Rev. 2014; 29 CD003824

[6]  Messerli FH, Bangalore S. Half a century of hydrochlorothiazide: facts, fads, fiction, and follies. Am J Med. 2011; 124 896–9.
Half a century of hydrochlorothiazide: facts, fads, fiction, and follies.CrossRef | 1:CAS:528:DC%2BC3MXht1GgsbbM&md5=e8f2e2d08242069cc663ae5bdeef412aCAS |

[7]  Wilson JM, Jungner G. Principles and practice of screening for disease. Geneva: World Health Organization; 1968.

[8]  Feigin VL, Lawes CM, Bennett DA, et al. Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review. Lancet Neurol. 2009; 8 355–69.
Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review.CrossRef |

[9]  Wikstrand J, Warnold I, Olsson G, et al. Primary prevention with metoprolol in patients with hypertension. Mortality results from the MAPHY study. JAMA. 1988; 259 1976–82.
Primary prevention with metoprolol in patients with hypertension. Mortality results from the MAPHY study.CrossRef | 1:STN:280:DyaL1c7lsFygsg%3D%3D&md5=79e4c0384ca2e4837fa7747ab10b7aeaCAS |

[10]  MRC Working Party MRC trial of treatment of mild hypertension: principal results. Medical Research Council Working Party. Br Med J (Clin Res Ed). 1985; 291 97–104.
MRC trial of treatment of mild hypertension: principal results. Medical Research Council Working Party.CrossRef |

[11]  Wilhelmsen L, Berglund G, Elmfeldt D, et al. Beta-blockers versus diuretics in hypertensive men: main results from the HAPPHY trial. J Hypertens. 1987; 5 561–72.
Beta-blockers versus diuretics in hypertensive men: main results from the HAPPHY trial.CrossRef | 1:STN:280:DyaL1c7hs1KnsA%3D%3D&md5=48004dc397dbd87a456d1e5d9fc35898CAS |

[12]  Reader R. The Australian therapeutic trial in mild hypertension. Report by the Management Committee. Lancet. 1980; 1 1261–7.

[13]  Smith WM. Treatment of mild hypertension: results of a ten-year intervention trial. Circ Res. 1977; 40 I98–105.
| 1:STN:280:DyaE2s7mtVCktw%3D%3D&md5=6751763bb9d1120ab7f8c4eecc582918CAS |

[14]  Furberg CD, Wright JT, Davis BR, et al. 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). JAMA. 2002; 288 2981–97.
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).CrossRef | 1:CAS:528:DC%2BD3sXhslWr&md5=6747a22e5a0a08d4b39f2c529e4b0961CAS |

[15]  Furberg CD, Wright JT, Davis BR, et al. Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: the Antihypertensive and Lipid-Lowering Treatment to prevent Heart Attack Trial (ALLHAT). JAMA. 2000; 283 1967–75.
Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: the Antihypertensive and Lipid-Lowering Treatment to prevent Heart Attack Trial (ALLHAT).CrossRef | 1:CAS:528:DC%2BD3cXjtVOjt74%3D&md5=18cecfa698071ca9bba3a6b00e621f48CAS |

[16]  Perry HM, Smith WM, McDonald RH, et al. Morbidity and mortality in the Systolic Hypertension in the Elderly Program (SHEP) pilot study. Stroke. 1989; 20 4–13.
Morbidity and mortality in the Systolic Hypertension in the Elderly Program (SHEP) pilot study.CrossRef |

[17]  Ernst ME. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). SHEP Cooperative Research Group. JAMA. 1991; 265 3255–64.
Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). SHEP Cooperative Research Group.CrossRef |

[18]  Malacco E, Mancia G, Rappelli A, et al. Treatment of isolated systolic hypertension: the SHELL study results. Blood Press. 2003; 12 160–7.
Treatment of isolated systolic hypertension: the SHELL study results.CrossRef | 1:CAS:528:DC%2BD3sXmt1Wnurk%3D&md5=8660c4c9b0ba1588fd33528456563be9CAS |

[19]  Amery A, Birkenhager W, Brixko P, et al. Mortality and morbidity results from the European Working Party on High Blood Pressure in the Elderly trial. Lancet. 1985; 325 1349–54.
Mortality and morbidity results from the European Working Party on High Blood Pressure in the Elderly trial.CrossRef |

[20]  Borhani NO, Mercuri M, Borhani P, et al. Final outcome results of the Multicenter Isradipine Diuretic Atherosclerosis Study (MIDAS): a randomized controlled trial. JAMA. 1996; 276 785–91.
Final outcome results of the Multicenter Isradipine Diuretic Atherosclerosis Study (MIDAS): a randomized controlled trial.CrossRef | 1:CAS:528:DyaK28XlvFOls7c%3D&md5=7499839d5feb1a7060bc7561fee7dab9CAS |

[21]  Brown MJ, Palmer C, Castaigne A, et al. Morbidity and mortality in patients randomised to double-blind treatment with a long-acting calcium-channel blocker or diuretic in the International Nifedipine GITS study: Intervention as a Goal in Hypertension Treatment (INSIGHT). Lancet. 2000; 356 366–72.
Morbidity and mortality in patients randomised to double-blind treatment with a long-acting calcium-channel blocker or diuretic in the International Nifedipine GITS study: Intervention as a Goal in Hypertension Treatment (INSIGHT).CrossRef | 1:CAS:528:DC%2BD3cXls1Clu7c%3D&md5=feb08c4c5d5380f700cb17464210af49CAS |

[22]  Jamerson K, Weber M, Bakris G, et al. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N Engl J Med. 2008; 359 2417–28.
Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients.CrossRef | 1:CAS:528:DC%2BD1cXhsVCrurjJ&md5=fbae404e0f669017915df53403121feeCAS |

[23]  Party MW. Medical Research Council trial of treatment of hypertension in older adults: principal results. MRC Working Party. BMJ. 1992; 304 405–12.
Medical Research Council trial of treatment of hypertension in older adults: principal results. MRC Working Party.CrossRef |

[24]  Veterans Administration Cooperative Study Group Effects of treatment on morbidity in hypertension. Results in patients with diastolic blood pressures averaging 115 through 129 mm Hg. JAMA. 1967; 202 1028–34.
Effects of treatment on morbidity in hypertension. Results in patients with diastolic blood pressures averaging 115 through 129 mm Hg.CrossRef |

[25]  Veterans Administration Cooperative Study Group Effects of treatment on morbidity in hypertension. II. Results in patients with diastolic blood pressure averaging 90 through 114 mm Hg. JAMA. 1970; 213 1143–52.
Effects of treatment on morbidity in hypertension. II. Results in patients with diastolic blood pressure averaging 90 through 114 mm Hg.CrossRef |

[26]  Wing LM, Reid C, Ryan P, et al. A comparison of outcomes with angiotensin-converting-enzyme inhibitors and diuretics for hypertension in the elderly. N Engl J Med. 2003; 348 583–92.
A comparison of outcomes with angiotensin-converting-enzyme inhibitors and diuretics for hypertension in the elderly.CrossRef | 1:CAS:528:DC%2BD3sXhtVyqt74%3D&md5=16a278e223b67ff383dc9979b57620baCAS |

[27]  Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008; 358 1887–98.
Treatment of hypertension in patients 80 years of age or older.CrossRef | 1:CAS:528:DC%2BD1cXlt1Ggsbk%3D&md5=cb01541b50c6ee55b11f769f334e4d90CAS |

[28]  Bulpitt CJ, Beckett NS, Cooke J, et al. Results of the pilot study for the Hypertension in the Very Elderly Trial. J Hypertens. 2003; 21 2409–17.
Results of the pilot study for the Hypertension in the Very Elderly Trial.CrossRef | 1:CAS:528:DC%2BD3sXpsVGhsb8%3D&md5=b203b51dcd85755c6672241bd1c45b35CAS |

[29]  Helgeland A. Treatment of mild hypertension: a five year controlled drug trial. The Oslo study. Am J Med. 1980; 69 725–32.
Treatment of mild hypertension: a five year controlled drug trial. The Oslo study.CrossRef | 1:STN:280:DyaL3M%2FlvFKiug%3D%3D&md5=f607d18fe77491595a4414f4212509c1CAS |

[30]  Barber J, McKeever TM, McDowell SE, et al. A systematic review and meta-analysis of thiazide-induced hyponatraemia: time to reconsider electrolyte monitoring regimens after thiazide initiation? Br J Clin Pharmacol. 2015; 79 566–77.
A systematic review and meta-analysis of thiazide-induced hyponatraemia: time to reconsider electrolyte monitoring regimens after thiazide initiation?CrossRef | 1:CAS:528:DC%2BC2MXkvFCktb0%3D&md5=a4d107475ed9400be89d726790fe5c1bCAS |

[31]  Zanchetti A, Agabiti Rosei E, Dal Palu C, et al. The Verapamil in Hypertension and Atherosclerosis Study (VHAS): results of long-term randomized treatment with either verapamil or chlorthalidone on carotid intima-media thickness. J Hypertens. 1998; 16 1667–76.
The Verapamil in Hypertension and Atherosclerosis Study (VHAS): results of long-term randomized treatment with either verapamil or chlorthalidone on carotid intima-media thickness.CrossRef | 1:CAS:528:DyaK1MXms1Sh&md5=adb56148ca291ffb878b61b7509570ddCAS |

[32]  Roush GC, Holford TR, Guddati AK. Chlorthalidone compared with hydrochlorothiazide in reducing cardiovascular events: systematic review and network meta-analyses. Hypertension. 2012; 59 1110–7.
Chlorthalidone compared with hydrochlorothiazide in reducing cardiovascular events: systematic review and network meta-analyses.CrossRef | 1:CAS:528:DC%2BC38XntVSgs7o%3D&md5=89ccc6f22cdf9ec077283d3f8d2194fbCAS |

[33]  Fagard RH. The ALLHAT trial: strengths and limitations. J Hypertens. 2003; 21 229–32.
The ALLHAT trial: strengths and limitations.CrossRef | 1:CAS:528:DC%2BD3sXptFKrtg%3D%3D&md5=5e10635f09f8244104777d6d3106b44fCAS |


Full Text PDF (1.5 MB) Export Citation

View Altmetrics