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The Scandal of Uncontrolled Hypertension: A Widely-Overlooked Remedy

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This blog truly has the potential to reduce the risk of heart attack, stroke and other cardiovascular complications for millions of people who are living unnecessarily with uncontrolled hypertension. I urge you to read it, and to help circulate this blog and get the word out, particularly to anyone you know who has uncontrolled hypertension or who is on multiple drugs for hypertension.

The tragedy is that we have the drugs to bring resistant hypertension under control in most cases and reduce the risk of cardiovascular events. And the fix is not expensive; it doesn't require budget-busting new drugs or new technologies such as catheter ablations. It often lies in inexpensive, affordable drugs that are not new. One such drug class can solve uncontrolled hypertension in perhaps half of cases yet is widely under-prescribed and/or under-dosed, with tragic consequences. It is not receiving the attention or use it merits and needs.

That drug class is the diuretics. The right diuretic(s) at the right dose. Studies by me and by others demonstrating their effectiveness, and my experience with patient after patient who comes to me with uncontrolled hypertension, suggest that millions of patients have uncontrolled hypertension either because they are not on a diuretic, or are on an inadequate dose or the wrong diuretic. Many doctors are under the mistaken impression that if the usual dose didn't control your blood pressure, higher doses won't either. They are wrong. The studies have been done and tell us that they do, but many physicians just don't prescribe the needed dose or the right diuretic.

Diuretics are commonly called "water pills." They lower blood pressure by increasing urinary excretion of sodium, which also has the effect of relaxing constricted arteries. Many patients are surprised to learn that diuretics lower blood pressure as much as other blood pressure medications do, and even more in those whose hypertension is salt-sensitive. And in millions of patients, without the right diuretic regimen the blood pressure will never come under control, no matter how many other drugs are added.

Why don't doctors prescribe them to their best benefit? Partly because habits are slow to change. Partly it is economics. The pharmaceutical industry, selling newer and more expensive drugs, did its best to overstate the risk of harm associated with diuretics. It also has no interest in promoting the older inexpensive diuretics, or in funding studies to further document the benefit of increasing their use.

Many doctors withhold diuretics from patients who in the past have had diuretic-related problems such as a low blood sodium level, gout, muscle cramps or allergic reactions. However, if your hypertension cannot be controlled without a diuretic, there are usually ways to cautiously and safely prescribe one and get around these problems, rather than settle for living with uncontrolled hypertension.
Diuretics must be prescribed with judgment. There are many diuretics to choose from. Some will fit you and your hypertension better than others. Also, higher doses can cause harm if not prescribed wisely and usually should not be prescribed unless your blood pressure has failed to respond to a standard two-drug regimen. Fortunately, when you do need a higher dose, most side effects can be avoided by careful selection of the diuretic and dose.

Also, diuretics are not the answer for everyone. Hypertension is caused by different mechanisms in different patients. That is why different patients need and respond to different medications. Many patients need a diuretic, at the usual or at a high dose, but many others don't. Certain clues, such as older age, black race, reduced kidney function, a low blood renin level, and hypertension that has not responded to treatment with other drugs help tell us whether a diuretic is essential to your treatment. These clues are widely ignored.

The bottom line? If you or anyone you know has uncontrolled hypertension, modifying the diuretic could be the most important yet overlooked intervention to bring it under control. The research has been done and shows it. It isn't controversial. But the results are not promoted, and the crucial use of diuretics has not gained traction.

I discuss in in my book Hypertension and You, approaches to prescribing diuretics, for whom, which diuretic, which dose, and how to get around the problems that can stand in the way of their use. I am writing this blog to raise readers' awareness of this readily available solution, the need to be proactive in your treatment in order to get your blood pressure under control, and the need to get the word out.