geoffrey modest medical blogs

Another study came out with a bit of fanfare in the medical community, comparing the cardiovascular and safety outcomes in people on chlorthalidone vs hydrochlorothiazide (HCTZ) for hypertension, though I don’t think that this is a very useful study ( see  htn chlorthal vs hctz no diff jamaintmed2020 in dropbox, or doi:10.1001/jamainternmed.2019.7454 ) Details: -- a large network of databases of observational comparative cohort studies (LEGEND: Large-Scale Evidence Generation and Evaluation in a Network of Databases), using  large-scale propensity score stratification, accessed data from 2001-2019 -- they compared the outcomes for those patients newly put on chlorthalidone vs hydrochlorothiazide:     -- excluding those who had any known prior exposure to any hypertensive therapy, or had initiated another antihypertensive within 7 days after starting one of these diuretics     -- including those initiating another antihypertens...

A recent case-control study of a large, comprehensive Danish database found a significant connection between patients prescribed hydrochlorothiazide (HCTZ) and the risk of malignant melanoma (see  htn hctz melanoma jamaintmed2018 in dropbox, or  doi:10.1001/jamainternmed.2018.1652 ). Details: -- 19,273 patients with histologically verified melanoma were compared to 192,730 population controls. -- All were without a prior history of cancer (except non-melanoma skin cancer), organ transplant, HIV infection, or azathioprine use Results: -- those who ever used HCTZ: 1958 melanoma cases vs 17,244 in controls; 17% increase with HCTZ (1.11-1.23), controlling for age, sex, history of nonmelanoma skin cancer, other comorbidity (diabetes, COPD, alcohol use disorder, chronic renal failure), Charlson Comorbidity Index score, highest level of the achieved education, and use of specific drugs (topical or oral retinoids, tetracycline, macrolides, aminoquinolones, amiodaron...

A recent analysis of 24-h ambulatory blood pressure monitoring (ABMP) compared hydrochlorothiazide (HCTZ) with chlorthalidone, finding poor overall blood pressure control with HCTZ  ( s ee  htn chlorthal vs hctz jacc2016  in dropbox, or Pareek AK. J Am Coll Cardiol 2016;67:379​). details: --54 Indian outpatients with stage 1 hypertension (140-159/90-99 mmHg, diagnosed at office visits and confirmed by 24-h ABPM) were randomized to chlorthalidone 6.25mg vs HCTZ 12.5mg vs a sustained released HCTZ (HCTZ-CR) 12.5mg. followed for 12-weeks [they chose the 6.25mg dose of chlorthalidone, since studies have found it to be 1.5-2.0 x more effective than HCTZ and have a much longer duration of action] --mean age 46, 50% female, BMI 27, BP 148/93, 10% current smokers --ABPM was done at baseline, 4 weeks, 12 weeks --results:     ​--significant decrease in daytime systolic and diastolic blood. at week 12: ...

The point of this email is to present some of the new literature on hypertension, which could impact clinical practice.  The summaries below are quite brief, but lots of info in the articles.   NICE  (National institute for health and clinical excellence, in the UK, which sends out recommendations for many clinical issues -- well-researched and probably less influenced by pharmaceutical money, etc -- see  htn nice recs 2011  and  htn nice recs summary 2011  in dropbox).  These are very thoughtful guidelines with some major changes over JNC here (though rumor has it that a revised JNC is on the near horizon). A few very notable changes:   --hctz should not be first line, and that in general, ccb's be used first line in people over 55yo and in african-caribbean patients, while ace/arb's be used in under 55yo non-african descent (use with care for women who might become pregnant, though there was an article suggesting that ACE-I not so ...