REPLY
Prazosin, Diuretics, and Glucose Intolerance
Alan N. Peiris;
Majula K. Pandit; and
Anil Minocha
15 October 1993 | Volume 119 Issue 8 | Pages 859-860
IN RESPONSE:
We thank Drs. Ross and Moser for their comments. The meta-analysis they cite indicates a significant reduction in coronary heart disease; however, this needs to be confirmed by carefully done prospective studies in view of the extensive literature indicating that thiazide diuretics may not significantly reduce coronary artery disease despite achieving adequate blood pressure control [1]. Moreover, thiazides neither induce regression of left ventricular hypertrophy nor reduce the risk for cardiac arrhythmias, which may predispose patients to sudden death [2]. The diabetogenic effects of thiazides are well described. We believe that further sophisticated studies of pulsatile insulin secretion [3] with long-term thiazide use may provide additional insight into the relation between thiazide diuretics and glucose tolerance. Abnormalities in pulsatile insulin secretion are among the earliest abnormalities to appear in states of glucose intolerance and deserve further study [4].
We appreciate Dr. Berlin's comments. Several studies (5 [additional references available from authors]) indicate that prazosin and related compounds may improve glucose intolerance when used as a single agent or in combination with known diabetogenic agents such as thiazide diuretics. The mechanisms by which prazosin, a predominantly 
-1 blocker, may influence glucose insulin homeostasis need further investigation but, as Dr. Berlin suggests, because increased muscle blood flow may play a role.
1. Ames RP. Negative effects of diuretic drugs on metabolic risk factors for coronary heart disease: possible alternative drug therapies. Am J Cardiol. 1983; 51:632-8.
2. Messerli FH, Nunez BD, Nunez MM, Garavaglia GE, Schmieder RE, Ventura HO. Hypertension and sudden death. Disparate effects of calcium entry blocker and diuretic therapy on cardiac dysrhythmias. Arch Intern Med. 1989; 149:1263-7.
3. Peiris AN, Stagner JI, Vogel RL, Nakagawa A, Samols E. Body fat distribution and peripheral insulin sensitivity in healthy men: role of insulin pulsatility. J Clin Endocrinol Metab. 1992; 75:290-4.
4. Polonsky KS, Given BD, Hirsch LJ, Tillil H, Shapiro ET, Beebe C, et al. Abnormal patterns of insulin secretion in non-insulin-dependent diabetes mellitus. N Engl J Med. 1988; 318:1231-9.
5. Khoury AF, Kaplan NM. Alpha-blocker therapy of hypertensives: an unfulfilled promise. JAMA. 1991; 266:394-8.
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