What is the recommended diuretic treatment for Hypertension (Htn)?

Recommended Diuretic Treatment for Hypertension

Thiazide-type diuretics are recommended as first-line therapy for most patients with hypertension, with chlorthalidone being the preferred agent due to its superior efficacy and longer duration of action compared to hydrochlorothiazide. 1

First-Line Diuretic Options

• Chlorthalidone is the preferred thiazide-like diuretic with initial dosing of 12.5-25 mg once daily (maximum 100 mg) and a long duration of action (24-72 hours) 1, 2
• Hydrochlorothiazide is an alternative thiazide diuretic at 12.5-25 mg once or twice daily (maximum 200 mg) with shorter duration of action (6-12 hours) 1, 3
• Indapamide 2.5 mg once daily (maximum 5 mg) with a long duration of action (36 hours) is another thiazide-like option 1

Rationale for Thiazide Preference

Thiazide diuretics have demonstrated efficacy in:

• Reducing blood pressure effectively at low doses 4
• Decreasing cardiovascular morbidity and mortality in clinical trials 2
• Providing more persistent antihypertensive effects in hypertensive patients 1
• Being cost-effective compared to other antihypertensive agents 5

Special Population Considerations

• Black patients: Initial antihypertensive treatment should include a diuretic or calcium channel blocker, either alone or in combination with a RAS blocker 1
• Resistant hypertension: Add spironolactone (25 mg daily) to existing regimen; if not tolerated, consider eplerenone, higher-dose thiazide/thiazide-like diuretic, or loop diuretic 1
• Chronic kidney disease with eGFR <30 mL/min: Loop diuretics (furosemide, torsemide, bumetanide) may be necessary for effective volume and blood pressure control 1

Dosing Considerations

• Low-dose therapy (12.5 mg hydrochlorothiazide or 15 mg chlorthalidone) is often sufficient to achieve blood pressure reduction while minimizing metabolic side effects 4, 6
• Stepwise approach: Start with low doses and titrate as needed based on blood pressure response 1
• Combination therapy: Thiazide diuretics significantly improve blood pressure control when combined with other antihypertensive classes 1

Potential Adverse Effects

• Electrolyte disturbances: Monitor for hypokalemia and hypomagnesemia, especially at higher doses 6
• Metabolic effects: May cause hyperglycemia, increased uric acid levels, and transient lipid elevations 5, 7
• Volume depletion: Can lead to hypotension and azotemia, particularly with inappropriate high doses 1

Clinical Pearls

• Chlorthalidone has been shown to be more effective than hydrochlorothiazide in lowering blood pressure, particularly during nighttime hours 1
• Diuretics enhance the antihypertensive efficacy of multidrug regimens 1
• Potassium-sparing diuretics (spironolactone, eplerenone) may be added when hypokalemia is a concern or in resistant hypertension 1, 8
• Thiazide-like diuretics (chlorthalidone, indapamide) have more cardiovascular risk reduction data than hydrochlorothiazide 1

Common Pitfalls to Avoid

• Underutilization of diuretics despite strong evidence supporting their use 1
• Using inappropriately high doses leading to unnecessary metabolic side effects 6
• Failing to monitor electrolytes, particularly in elderly patients or those on digitalis 5
• Not considering a loop diuretic when eGFR is <30 mL/min 1