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Hydrochlorothiazide is not the most useful nor versatile thiazide diuretic

Purpose of review To determine usefulness and versatility of hydrochlorothiazide (HCTZ) relative to other thiazide diuretics in the treatment of hypertension. Recent findings HCTZ was found to be less potent in lowering blood pressure (BP) than other thiazide diuretics, including chlorthalidone (CTD) and bendroflumethiazide. A recent meta-analysis also suggested HCTZ (12.5–25 mg daily) to be less potent than antihypertensive agents from several other classes, including angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and calcium antagonists. The risk of hyponatremia, hypokalemia, and hyperuricemia associated with HCTZ was lower than with CTD, while the risk of gouty arthritis was similar. Despite lower risks of metabolic side-effects, meta-analysis of clinical trials showed that, for any given difference in achieved clinic SBP, HCTZ therapy was associated with 18% higher adverse cardiovascular events when compared with CTD. Summary Increasing evidence suggests inferiority of HCTZ in lowering BP and cardiovascular outcomes in hypertensive patients when compared with other drugs in the same class, particularly CTD and indapamide. Thus, HCTZ is neither more useful nor more versatile than other thiazide diuretics. CTD and indapamide should be preferred over HCTZ in most hypertensive patients when diuretics are required for treatment of hypertension.