Lessons from ALLHAT. Are low budget diuretics first line therapy in hypertension?

Diuretics are well-established and nowadays also cheap cardiovascular agents. In contrast to the most recent American hypertension guidelines (JNC 7) which ascribe a singular place to diuretics in the first-line treatment of hypertension following a one-sided interpretation of the ALLHAT results, in the balanced guidelines of the European Society of Hypertension (ESH) published in 2003, they are placed alongside beta-blockers, ACE inhibitors, sartans and calcium antagonists as the drugs of first choice, but not given preference. Previous scientific evidence and clinical experience is to a certain extent in line with this classification of diuretics. On the basis of the indisputable dose-dependent potential for side-effects such as hypokalaemia, diabetogenicity and stimulation of neurohumoural systems, I personally consider diuretics to be inferior to the more recent substance groups, particularly the RAS inhibitors. I would therefore welcome it if diuretics in the future were removed from the monotherapy of hypertension and offered from the outset as low-dosed combination partners for RAS inhibitors, beta-blockers and also calcium antagonists. In this role they could only do good and not cause any damage.