University Hospital Heidelberg, Department of General Practice and Health Services Research, Heidelberg, Germany.
Curr Med Res Opin. 2011 Mar;27(3):497-502. doi: 10.1185/03007995.2010.547932. Epub 2011 Jan 6.
Internationally there is an ongoing debate on diuretics as first-line therapy for most patients with hypertension. In spite of many arguments against them in antihypertensive monotherapy, the authors of the present study perceived them to be regularly prescribed in combination therapy in Germany. The study objective was to look for this discrepancy in prescribing reality as a contribution from clinical practice to an academic debate.
A descriptive cross-sectional study in a yearly contact group (YCG; 1.7.2007-31.06.2008) was conducted based on data from a scientific network of 22 general practitioners in Germany. All patients with hypertension as diagnosed by their general practitioner were included. Antihypertensives were grouped according to the ATC classification. To assess for potential design effects by the given two-level setting, 95% confidence intervals (CI) were adjusted for clustering.
Hypertension had been diagnosed in 9.3% of the 58 852 patients. Of these, 21.6% received no antihypertensives. Of those who were treated, 30.6% (CI [28.6-32.6]) had monotherapy. In monotherapy, 8.6% (CI [7.1-10.2]) were prescribed some diuretic, 1.5% (CI [0.5-3.0]) received hydrochlorothiazide (HCT). Combination therapy was prescribed to 69.4% (CI [67.2-71.6]). These patients received some diuretic in 79.0% (CI [76.9-81.0]) of the cases, of which 80.8% (CI [78.5-83.1]) had a combination with HCT. HCT was prescribed in 76.2% (CI [73.5-78.9]) in fixed-dose formulations.
In spite to the many arguments against them, leading to their almost complete disregard in monotherapy, thiazide-diuretics seem to be standard in combination therapy in Germany. This inconsistency can not be explained by the arguments of the current debate. Key limitations of the present study include the lack of ability to tell whether a given monotherapy is the first-line medication, the small sample size and the possible selection bias.
国际上对于利尿剂是否应作为大多数高血压患者的一线治疗药物一直存在争议。尽管在抗高血压单药治疗中存在许多反对利尿剂的观点，但本研究的作者认为，在德国，利尿剂经常被用于联合治疗。本研究的目的是从临床实践的角度出发，探寻处方实践与学术争论之间的差异。
该研究基于德国一个由 22 名全科医生组成的科学网络的数据，开展了一项描述性的年度接触组研究（2007 年 7 月 1 日至 2008 年 6 月 31 日）。所有被其全科医生诊断为高血压的患者均被纳入研究。抗高血压药物根据 ATC 分类进行分组。为了评估由给定的两级设置引起的潜在设计效果，95%置信区间（CI）进行了聚类调整。
在 58852 名患者中，有 9.3%被诊断为高血压。其中，21.6%未接受任何抗高血压药物治疗。在接受治疗的患者中，30.6%（95%CI [28.6-32.6]）接受了单药治疗。在单药治疗中，8.6%（95%CI [7.1-10.2]）使用了利尿剂，1.5%（95%CI [0.5-3.0]）使用了氢氯噻嗪（HCT）。69.4%（95%CI [67.2-71.6]）接受了联合治疗。在这些接受联合治疗的患者中，79.0%（95%CI [76.9-81.0]）使用了利尿剂，其中 80.8%（95%CI [78.5-83.1]）使用了 HCT。HCT 以固定剂量配方使用的比例为 76.2%（95%CI [73.5-78.9]）。
尽管存在许多反对利尿剂的观点，导致其在单药治疗中几乎被完全忽视，但噻嗪类利尿剂似乎是德国联合治疗的标准药物。这种不一致性不能用当前争论的观点来解释。本研究的主要局限性包括无法确定给定的单药治疗是否为一线药物、样本量小以及可能存在选择偏倚。
