Thiazides: do they kill?

In 2000 and 2002 after the ALLHAT-study had been published [1,2] there was a paradigm shift in the use of thiazides. ALLHAT was a study of cardiovascular endpoints in relation to different antihypertensive treatments in 33 357 hypertensive patients observed over an average of 4.9 years. The study [1,2] found no differences between the three treatment groups [diuretics in the form of chlorthalidone vs calcium antagonists (amlodipine) vs ACEI (lisinopril)]. Consequently, after ALLHAT, it was emphasized that thiazides ought to be an integral part of the hypertensive patient’s prescription sooner or later—and health policy makers clearly favoured ‘sooner’ over ‘later’ because of their low cost. Indeed, the sale of thiazide-like agents has more than doubled between 2001 and 2004 in Germany alone. In the meantime, quite a few articles have dealt with the pros and cons of thiazides [3], when prescribed on such an extended basis. However, there appears to be yet another important side-effect of thiazides that is frequently missed—even though it may kill patients. This will be discussed herein.