Concerning ALLHAT

A reader posted this comment/question today:

Hi Medrants,

Your salary won’t be increasing with the ridiculous cost of drugs. The notion that extremely expensive ACE-I are either no better or potentially less effective than thiazide diuretics represents a huge waste of ((LIMITED)) health care dollars. Please choose one of the following:
1) Stick with your current salary and prescribe whichever antihypertensive you like.

2) Prescribe thiazides first line and advocate some of the money previously wasted on ACE-Is goes to help providing comprehensive outpatient care.

1 or 2 ?

First, I learned many years ago that hypotheticals are dangerous. Lawyers love to pose them to make rhetorical points. They are tricky to answer.

This question has several flaws. First, ACE inhibitors are no longer ridiculously expensive. Second, for many patients they may even save costs (i.e., less CHF, less progression of CAD, less onset of diabetes mellitus). Thus, the question as framed lacks coherence.

Please refer to my many commentaries on ALLHAT. Diuretics rarely control BP alone. Most patients require two drugs for adequate control. In many subgoups the evidence supports ACE inhibitors plus a diuretic as the best combination.

My critiques of ALLHAT stem from designing a study which does reflect practice. If an ACE inhibitor alone does not control the BP, the next logical drug is a thiazide diuretic. Almost any class of antihypertensives benefits from adding a thiazide.

To me the importance of ALLHAT is that thiazides do work. However, when one adds all additional evidence, many subgroups – type II diabetes mellitus, proteinuric chronic kidney disease and known CAD in particular – have great benefit from an ACE inhibitor. I generally start with an ACE inhibitor, and quickly add a low dose of a diuretic if adequate pressure is not achieved with an ACE alone. ALLHAT does not provide the data for that treatment plan, because it was designed for a different less important question.