2017.02.14 04:13
Compared with other hypertensive medications, the use of thiazide-type diuretic therapy was beneficial in reducing hip and pelvic fracture risk in older adults, a recent study found. This study examined hip and pelvic fracture hospitalizations in Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) participants randomized to first-step therapy with a thiazide-type diuretic (chlorthalidone), a calcium channel blocker (amlodipine besylate), or an angiotensin-converting enzyme inhibitor (lisinopril). Recruitment was from February 1994 to January 1998; in-trial follow-up ended in March 2002. The mean follow-up was 4.9 years. Researchers found:
Citation:
Puttnam R, Davis BR, Pressel SL, for the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) Collaborative Research Group. Association of 3 different antihypertensive medications with hip and pelvic fracture risk in older adults. Secondary analysis of a randomized clinical trial. JAMA Intern Med. 2017;177(1):67-76. doi:10.1001/jamainternmed.2016.6821.
Commentary:
The Eighth Joint National Committee (JNC 8) recommends initial treatment with an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic in the nonblack hypertensive population, and in the black hypertensive population a calcium channel blocker or thiazide-type diuretic.1 In the ALLHAT trial, the largest randomized trial on antihypertensive treatment ever conducted, chlorthalidone was superior to amlodipine and lisinopril in preventing heart failure, and to lisinopril (blacks only) in preventing stroke.2 Demonstrating a 21% decreased risk of hip and pelvic fractures, this current study is consistent with a previous meta-analysis of 21 case-control and cohort studies that showed a 24% decrease in risk of hip fracture compared with other antihypertensive agents.3 The consistency of these observational and randomized trial results (decreased incidence of osteoporotic fractures with thiazide-like diuretics and the demonstrated superiority of thiazides on cardiovascular endpoints) provides strong rationale to choose this inexpensive, effective class of mediations as our first-line antihypertensive agent of choice. —Neil Skolnik, MD
2017.02.14 04:25
2017.02.14 04:49
One of the common causes of kidney stones, aside from hyperparathyroidism, is
idiopathic hypercalciuria, which requires 24 hour urine collection for diagnosis.
After a diagnosis of kidney stone is established, ruling out hyperparathyroidism and
idiopathic hypercalciuria should be a routine part of the diagnostic work up.
Unfortunately urologists and many internists neglect to do 24 hour urine collection
to rule out the hpercalciuria so that the patient would come back with the recurrence of kidney stones.
I have a personal experience on this subject. I had kidney stone twice one year apart some 20 years ago
and self diagnosed myself to have had the idiopathic hypercalciuria for which I put myself on
hydrochlorthiazide 12.5 mg q d and confirmed the correction of the hypercalciuria by repeating the 24 hr urine test.
I've had no recurrence since so far.
Obviously taking thiazides for any reason helps retain calcium which in turn strengthening our bones to prevent fractures.
2017.02.14 14:38
I take hydrochlorothiazide 25mg/day for my borderline high BP.
It didn't really help in lowering my borderline BP.
Only when I take double dose (50mg), I feel diuresis. No side effects.
I did not realize that it does help to strengthen my skeletal structures.
In that case, I may continue my HCTZ which cost $4 for 30 pills.
Funny thing...
If I buy 30 pills, it cost $4 but if I buy 31 pills (as you know, some month has 31 days),
it cost $8 as my insurance considers it as two months supply,
meaning that 31 or 60 pills cost the same.
2017.02.14 16:54
In this study they used chlorthalidone 25mg q d which has longer duration than that of hydrochlorthiazide
so that perhaps it has more diuresis and more antihypertensive effect.
In America, most practitioners choose hydrochlorthiazide for fear of the greater chance of hypokalemia
which rarely can occur in spite of bananas and oranges to supplement potassium.
Sometimes I take 25mg as well when I eat Korean food. Taking 25mg q d can rarely bring on hypokalemia.
Taking 50mg q d will have a greater chance of bringing on hypokalemia.
As you know, hypokalemia can bring on arrhythmia.
Most cardiologists would prescribe dyazide capsule one q d if his patient needs to take hydrochlorthiazide 25 mg q d.
Dyazide has hctz 25 mg plus potassium saving med, Triamterene.
Or simply add another Rx for KCL 10meq q d.
The reason for this is that 10 meq of KCL is equal to about 6 bananas so that eating one or two bananas a day is not enough.
If hydrochlorthiazide 25mg q d does not control your BP satisfactorily, you would consider adding angiotensin receptor blockers
such as losartan, candesartan, etc at the lowest dosage.
2017.02.15 05:30
Actually, I talked to my family doctor (who is my daughter's partner) to give me HCTZ
because I read somewhere that it works well for "Kim-Chee"-eating Koreans.
My serum potassium level is always normal.
My young family doctor always do whatever I say but I won't know what he's going to say
if I ask him for one of the angiotensin receptor blockers.
Well, live like a snappy young man in the way I am now,
or take the new pills and then live like a withered old man??
2017.02.15 07:33
You were correct, and I am proud of your selecting HCTZ.
HCTZ works well not only for Asiatics but for the elderly.
It is good to know that Potassium level was normal with 25mg q d,
which is usually the case.
However, as I said, rarely hypokalemia can develop especially when
you are doing a high level exertion and sweating in hot weather, etc.,
so that you need to take precaution by supplementing potassium.
On the contrary to what you stated, keeping the BP at the ideal level,
would increase cardiac output by lowering vascular resistance(cardiac output equal to BP divided by
vascular resistance) and will make you snappier, in my opinion.
Forgive me for this boring lecture, which as you know is elementary stuff.
2017.02.15 08:00
Major factors influencing stroke volume – Multiple factors impact preload, afterload, and contractility, and are the major considerations influencing SV.[7]Cardiac output equals stroke volume times heart rate. Aterload is blood pressure so that decreasing BP to normal decreases the afterload and increases the stroke volume and cardiac output giving you more energy.
2017.02.15 10:29
http://www.nejm.org/doi/pdf/10.1056/NEJM199406303302603
This was an important study which became one of guidelines
for practicing internists until now as far as using thiazides diuretics on long term basis.
My statements earlier are based on this particular study besides my personal observations
as a medical practitioner.
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The mechanism of action of thiazides in lowering blood pressure in the long term is not fully understood. When administered acutely thiazides lower blood pressure by causing diuresis, a fall in plasma volume and a reduction in cardiac output. However, after chronic use thiazides cause a reduction in blood pressure by lowering peripheral resistance (i.e. vasodilation). The mechanism of this effect is uncertain but it may involve effects on 'whole body' or renal autoregulation, or direct vasodilator actions either through inhibition of carbonic anhydrase[12] or by desensitizing the vascular smooth muscle cells to the rise in intracellular calcium induced by norepinephrine.[13]
Thiazides also lower urinary calcium excretion, making them useful in preventing calcium-containing kidney stones. This effect is associated with positive calcium balance and is associated with an increase in bone mineral density and reductions in fracture rates attributable to osteoporosis.[14] By a lesser understood mechanism, thiazides directly stimulate osteoblastdifferentiation and bone mineral formation, further slowing the course of osteoporosis.[15]
Because of their promotion of calcium retention, thiazides are used in the treatment of
Mechanisms of action
The members of this class of diuretics are derived from benzothiadiazine. They control hypertension in part by inhibiting reabsorption of sodium (Na+) and chloride (Cl−) ions from the distal convoluted tubules in the kidneys by blocking the thiazide-sensitive Na+-Cl− symporter.[16] The term "thiazide" is also often used for drugs with a similar action that do not have the thiazide chemical structure, such as chlorthalidone and metolazone. These agents are more properly termed thiazide-like diuretics.
Thiazide diuretics also increase calcium reabsorption at the distal tubule. By lowering the sodium concentration in the tubule epithelial cells, thiazides indirectly increase the activity of the basolateral Na+/Ca2+ antiporter. This facilitates the transport of Ca2+ from the epithelial cells into the renal interstitium. This movement of Ca2+, in turn, decreases the intracellular Ca2+concentration, which allows more Ca2+ to diffuse from the lumen of the tubules into epithelial cells via apical Ca2+-selective channels (TRPV5). In other words, less Ca2+ in the cell increases the driving force for reabsorption from the lumen.[17]
Thiazides are also thought to increase the reabsorption of Ca2+ by a mechanism involving the reabsorption of sodium and calcium in the proximal tubule in response to sodium depletion. Some of this response is due to augmentation of the action of parathyroid hormone.[18](from Internet)