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Response to Letter "ACE-Inhibitors and diuretics, optimal combination therapy"
Submit responseWe thank Dr. Krantz for his thoughtful letter (1). The proposed strategy of using a diuretic and ACE inhibitor simultaneously is supported by the effects of combined treatment in the PROGRESS trial (2), but that study could also be (and was) interpreted as showing that it's the blood pressure that matters, especially for stroke, and blood pressure reduction is much more effective with a diuretic in the regimen. Although, in theory, the use of ACE inhibitors could offset the metabolic effects (higher glucose, lower potassium) of thiazides, other potassium-sparing regimens may be just as or more effective, and a randomized trial to compare such regimens would be valuable. In addition, minimizing the metabolic effects would not necessarily translate into lower rates of important clinical outcomes, including coronary heart disease, stroke, and heart failure. Therefore, an events trial is also needed to test initiating treatment with different two-drug combinations wherein one of the medications is a thiazide diuretic.
References:
1. Krantz, Mori. ACE-Inhibitors and diuretics, optimal combination therapy [Letter]. Annals of Internal Medicine. 2004.
2. Chapman N, Huxley R, Anderson C, Bousser MG, Chalmers J, Colman S, et al. Effects of a perindopril-based blood pressure-lowering regimen on the risk of recurrent stroke according to stroke subtype and medical history: the PROGRESS Trial. Stroke. 2004;35:116-21. [PMID: 14671247]
Conflict of Interest:
Potential Financial Conflicts of Interest: Honoraria: PK Whelton (Pfizer), JT Wright (Astra, Aventis, Bayer, Bristol Myers Squibb, Merck & Co., Novartis Pharma AG, Pfizer, Phoenix Pharmaceuticals, Searle & Co., SmithKline Beechham, Solvay/Unimed); Grants received: JA Cutler (Pfizer, AstraZeneca, Bristol-Myers Squibb, JT Wright (AstraZeneca, Aventis, Bayer, Bristol-Myers Squibb, Eli Lilly & Co., Merck & Co., Novartis Pharma AG, Pfizer, Searle & Co., SmithKline Beechham, Solvay/Unimed); Consulting Fees: JT Wright (Astra, Aventis, Bayer, Bristol Myers Squibb, Merck & Co., Novartis Pharma AG, Pfizer, Phoenix Pharmaceuticals, Searle & Co., SmithKline Beechham, Solvay/Unimed)