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Diuretics

23 July 2007
The use of diuretics is well established in the treatment of hypertension. Thiazide diuretics are cheap and are the most widely used antihypertensive agents. When used in patients with essential hypertension and relatively normal renal function, thiazides are more potent than the loop diuretics. However in patients with renal insufficiency, thiazides are less effective and loop diuretics should be used instead.

In the elderly with no co-morbid conditions, diuretics are the drugs of choice in the treatment of systolic diastolic hypertension and isolated systolic hypertension. Diuretics not only reduce the incidence of fatal and non-fatal strokes but also cardiovascular morbidity and mortality and all-cause mortality. Several large clinical trials have also demonstrated that even low dose thiazides effectively lower BP.

Diuretics in combination with beta-blockers are effective in the treatment of hypertension in the elderly. They can also be used in combination with ACEIs for the treatment of heart failure. Low dose diuretics (e.g., hydrochlorothiazide < 25 mg) can potentiate the action of other antihypertensive agents with minimal adverse metabolic effects even in diabetic patients.

Diuretics should be avoided in patients with gout as they can precipitate an acute attack. Potassium-sparing diuretics may exacerbate hyperkalaemia due to ACEIs or ARBs and also in patients with underlying renal insufficiency.

Adverse effects are uncommon, unless high doses are used. These include increased serum cholesterol, glucose, uric acid and calcium levels; decreased potassium, sodium and magnesium levels; and erectile dysfunction. Potassium supplements may be required.

Diuretic Starting Dose
Recommended Maximum Dose
Chlorothiazide 250 mg 500 mg
Hydrochlorothiazide 12.5 mg 50 mg
Chlorthalidone 12.5 mg 50 mg
Amiloride/hydrochlorothiazide
5 mg/50 mg
1/2 tablet 1 tablet
Indapamide SR 1.5 mg 1.5 mg
Indapamide 2.5 mg 2.5 mg
Triamterene/hydrochlorothiazide
50 mg/25 mg
1 tablet 2 tablets

Table12: Diuretics commonly used for the treatment of hypertension in Malaysia

Reference
Clinical Practice Guidelines on the Management of Hypertension


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