GPs win on diuretic choice

GPs have welcomed NICE's decision to continue to recommend diuretics as a first-line treatment for the majority of hypertension patients.

The long-awaited final version of the joint NICE British Hypertension Society (BHS) clinical guideline on hypertension includes diuretics as first line in a shift in policy from draft guidance published in February.

The draft guidance named calcium-channel blockers (CCBs) as first-line treatment in patients older than 55 years or black, with diuretics only to be given if CCBs were inappropriate.

Previous NICE guidance, issued in 2004, differed markedly from the BHS's AB/CD guidelines in advising that thiazide diuretics be used first line in most patients, unless under 55, when a beta-blocker could be used.

Second-line therapy was beta-blocker, ACE inhibitor or angiotensin II receptor blocker (ARB), and CCBs were only to be added as third-line treatment.

Many GPs were critical of the draft guideline making thiazide diuretic an adjunct rather than first-line therapy. NICE received 160 responses during the consultation process on the draft.

Now NICE has changed its position again, stating that CCBs and diuretics are equally clinically and cost-effective as first-line therapy (see box).

Dr Terry McCormack, chairman of the Primary Care Cardiovascular Society and a GP in Whitby, North Yorkshire, said he was pleased that NICE had taken GPs' views into account.

'It makes perfect sense for CCBs and diuretics to be treated the same,' he said. 'The majority of GPs were using the AB/CD algorithm and were ignoring the previous NICE algorithm, but they will use this A/CD algorithm.'

Dr Mark Davis, Leeds GP and member of the guideline's development group, said: 'The main thing is to reduce blood pressure with a simple, pragmatic, evidence-based guideline.'

NICE has stuck with plans to move beta-blocker therapy from first-line to fourth-line treatment following concerns that the drugs might raise diabetes and stroke risk. For under-55s with hypertension, ACE inhibitors should now be used first line, with ARBs as an alternative.

But Professor Bryan Williams, from the University Hospitals NHS Trust in Leicester, and a member of the guideline development group, stressed that there was no need for hypertension patients taking beta-blockers to be switched to ACE inhibitors immediately.

'Patients who are well-controlled without any complications of beta-blockers should stay on them for the moment,' he said.

Beta-blockers should remain first-line therapy for women of childbearing age, he added.

Patients taking beta-blockers for other indications, such as angina, or who cannot tolerate alternatives should continue with their current treatment.

NICE GUIDELINE

Step 1 - ACE inhibitor or ARB (A) for those under 55; calcium-channel blocker (C) or thiazide diuretic (D) for patients over 55 and black patients.

Step 2 - A plus C or A plus D.

Step 3 - A plus C plus D.

Step 4 - Add other diuretics, alpha-blockers, or beta-blockers.

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