Diuretics: The Questions Continue

There is a myth abroad in the land that it is possible prospectively to select the appropriate antihypertensive drug with which to initiate therapy. This is euphemistically called “individualized” therapy. The concept is appealing, but there is no agreement among the “experts” about how to do this which confuses primary care physicians who ultimately treat most of the hypertensive patients. Our desire to individualize antihypertensive therapy greatly exceeds our ability to do so. More often than not, the selection of the appropriate antihypertensive agent is, at best, an educated guess, influenced by physiciansʹ preference, experience, and bias, as well as unique characteristics of the patient. When there are no compelling indications or contraindications for certain drugs, it is recommended that an oral diuretic in low-dose be prescribed because these agents have been shown in randomized trials to have few side effects, to enhance quality of life, to reverse left ventricular hypertrophy, and most importantly to reduce cardiovascular morbidity and mortality.