Hypertension Management

Introduction to Alternative Diuretics

Thiazide-like diuretics, such as chlorthalidone and indapamide, have longer duration of action and proven cardiovascular outcome benefits compared to conventional thiazide diuretics, and are recommended by the European Society of Cardiology 1, 2

Chlorthalidone is recommended at a dosage of 12.5-25.0 mg once daily, providing similar antihypertensive efficacy to indapamide 1.5-2.5 mg daily, and is supported by the American College of Cardiology 3
If chlorthalidone is unavailable or not tolerated, consider calcium channel blockers (e.g., long-acting amlodipine) or ACE inhibitors (e.g., lisinopril or ramipril) as first choice alternatives, with ARBs (e.g., losartan or valsartan) as options if ACE inhibitors cause cough or angioedema 1, 3
Beta-blockers should be avoided as first-line alternatives unless specific indications exist, such as coronary disease 1, 3

The recommended blood pressure target for most adults is <130/80 mmHg, according to multiple guidelines 4, 5
For older patients (≥65 years), the recommended systolic blood pressure target is 130-139 mmHg, as recommended by the European Society of Cardiology 2
For patients with specific characteristics, such as age ≥55 years or Black patients of any age, a calcium channel blocker is recommended as the first alternative, while for patients <55 years, an ACE inhibitor is recommended 3

For patients with heart failure, consider spironolactone (mineralocorticoid receptor antagonist), particularly beneficial in resistant hypertension, as recommended by the American College of Cardiology 6, 7
For patients with decreased renal function (eGFR <30 mL/min/1.73 m²), loop diuretics are preferred over thiazide-like diuretics 6

Regular monitoring of potassium and sodium is essential when switching between diuretics, and concomitant hypomagnesemia should not be overlooked 8
If monotherapy is insufficient, combine with ACE inhibitor/ARB or CCB based on patient characteristics, as recommended by the American College of Cardiology 3
Avoid assuming all diuretics have identical side effect profiles, and be aware of the different metabolic effects of chlorthalidone and indapamide compared to conventional thiazides 3