What is an equivalent alternative to indapamide (Indapamide) for a patient who tolerates it well but is currently unavailable?

Chlorthalidone is the Best Alternative to Indapamide for Hypertension Management

For patients who tolerate indapamide well but cannot access it, chlorthalidone (12.5-25.0 mg once daily) is the recommended alternative due to its similar pharmacological profile and proven cardiovascular benefits. 1

Rationale for Chlorthalidone as First Choice Alternative

Chlorthalidone and indapamide are both thiazide-like diuretics with several important similarities:

• Both have longer duration of action compared to conventional thiazide diuretics 2
• Both have proven cardiovascular outcome benefits 1
• Both maintain efficacy down to eGFR of 30 mL/min/1.73 m² 1

The 2024 ESC guidelines specifically recommend thiazide-like diuretics (such as chlorthalidone and indapamide) over conventional thiazides due to their superior efficacy and duration of action 2.

Dosing Recommendations

• Chlorthalidone: 12.5-25.0 mg once daily 2, 1
• This dosing provides similar antihypertensive efficacy to indapamide 1.5-2.5 mg daily 3

Alternative Options Based on Patient Characteristics

If chlorthalidone is unavailable or not tolerated, consider these alternatives based on patient demographics:

For Patients ≥55 Years or Black Patients of Any Age:

• First choice: Calcium channel blocker (e.g., amlodipine) 2, 1
• Long-acting amlodipine is specifically recommended as the preferred CCB 2

For Patients <55 Years (Non-Black):

• First choice: ACE inhibitor (e.g., lisinopril, ramipril) 2, 1
• If ACE inhibitor causes cough or angioedema, use an ARB (e.g., losartan, valsartan) 2

For Patients with Heart Failure:

• Consider spironolactone (mineralocorticoid receptor antagonist), particularly beneficial in resistant hypertension 1

Important Monitoring Considerations

When switching from indapamide to another diuretic:

• Monitor serum potassium and sodium levels within 1-2 weeks of switching 1
• Watch for metabolic effects - chlorthalidone may have slightly different metabolic profile than indapamide 1
• Be aware that chlorthalidone has a longer half-life than indapamide and may require dosage adjustment 3

Avoiding Common Pitfalls

• Do not substitute with hydrochlorothiazide unless absolutely necessary, as it has shorter duration of action (6-12 hours) and less potent antihypertensive effects than thiazide-like diuretics 1
• Don't overlook potential electrolyte disturbances, particularly hypokalemia and hypomagnesemia 1
• Avoid beta-blockers as first-line alternatives unless specific indications exist (e.g., coronary disease) 2

Blood Pressure Targets

Regardless of which alternative is chosen, maintain appropriate blood pressure targets:

• For most adults: <130/80 mmHg 2
• For older patients (≥65 years): 130-139 mmHg systolic 2

By following these recommendations, you can effectively manage hypertension in patients who previously responded well to indapamide but currently cannot access it.