Diuretics have been recommended as first-line treatment of
hypertension and are also valuable in the management of hypervolemia and
electrolyte disorders. This review summarizes the key features of the most commonly used
diuretics. We then provide an update of clinical trials for
diuretics during the past 5 years. Compared to other classes of medications,
thiazide diuretics are at least as effective in reducing cardiovascular events (CVEs) in patients with
hypertension and are more effective than β-blockers and
angiotensin-converting enzyme inhibitors in reducing
stroke. Observational cohort data and a network analysis have shown that CVEs are lowered by one-fifth from
chlorthalidone when compared to the commonly used
thiazide,
hydrochlorothiazide. Relative to placebo,
chlorthalidone increases life expectancy. In those aged 80 years and older, the
diuretic,
indapamide, lowers CVEs relative to placebo. The
aldosterone antagonist,
eplerenone, lowers total mortality in early
congestive heart failure. The benefit of
eplerenone following acute
myocardial infarction (MI) is limited to administration within 3 to 6 days post-MI.
Aldosterone antagonists have been shown to lower the incidence of
sudden cardiac death and to reduce
proteinuria. In the setting of
heart failure, long acting
loop diuretics azosemide and
torasemide are more effective in improving
heart failure outcomes than the far more commonly used short acting
furosemide. Evening dosing of
diuretics appears to lower CVEs relative to morning dosing. In conclusion,
diuretics are a diverse class of drugs that remain extremely important in the management of
hypertension and hypervolemic states.