Diuretics

a. Diuretics lower BP by inhibiting renal sodium and water reabsorption. Diuretics are considered first-line therapy in patients with uncomplicated hypertension or with systolic heart failure. They are drugs of choice for isolated systolic hypertension. Diuretics are effective agents in African-American and elderly patients, since they tend to be more renin-dependent than Caucasian hypertensive patients.

b. Hydrochlorothiazide (HCTZ) effectively lowers BP at doses as low as 12.5-25.0 mg qd. Its BP-lowering effect tends to plateau at doses above 25 mg/d.

c. Indapamide (Lozol) and metolazone (Zaroxolyn) are thiazide-like diuretics that are also dosed once a day but offer the advantage of being effective at a creatinine clearance as low as 20 mL/min.

Thiazide Diuretics

Drug

Usual dose

Maximum dose

Chlorthalidone (Hygroton)

12.5-25 mg qd

50 mg/d

Chlorothiazide (Diuril)

0.5-1 g/d (qd or bid)

2 g/d

Hydrochlorothiazide (HCTZ, Hydrodiuril)

12.5-25 mg qd

50 mg/d

Indapamide (Lozol)

1.25 mg qd

5 mg/d

Methyclothiazide (Enduron)

2.5 mg qd

5 mg/d

Metolazone (Zaroxolyn)

2.5-5 mg qd

5 mg/d

d. Thiazide diuretics may cause hypokalemia, hypomagnesemia, hyperuricemia, hypercalcemia, hyperlipidemia, and hyperglycemia. With long-term use, these side effects will usually return to baseline. Potassium or magnesium supplements may be necessary when a thiazide diuretic is used, but combining these agents with amiloride or triamterene may preclude the need for supplementation.

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