Older, cheaper drugs best first choice for high blood pressure in people with pre-diabetes

We've long recommended diuretics—the oldest, cheapest class of blood-pressure lowering drugs—for most people with high blood pressure. But one exception has been in people who have type 2 diabetes. In that case, newer and more expensive drugs called ACE inhibitors, such as enalapril (Vasotec and generic) and lisinopril (Prinivil and generic), offer special benefits, since they not only lower blood pressure but protect the kidneys from diabetes-related damage. Many doctors have long assumed those benefits also held true for people with the metabolic syndrome, a precursor to diabetes that multiplies the risk of heart disease. But a new study, published in the January 28 issue of the Archives of Internal Medicine, shows that those individuals should usually start with a diuretic too.

The trial, an influential study sponsored by the National Heart, Lung, and Blood Institute  called the "Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial", found that diuretics were also a better first choice than several other classes of medication, including alpha-blockers and calcium channel blockers. The diuretics were at least as effective as all those drugs in lowering blood pressure and preventing heart attack, and better at preventing heart failure or stroke. The benefits were especially striking in black people.  Generic diuretics can cost less than $5 a month, a fraction of what the other drugs cost.

Most people with high blood pressure—including those with signs of the metabolic syndrome, such as high triglycerides, a low level of HDL (good) cholesterol, and lots of abdominal fat—should now start with a diuretic.

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