To the Editor: The ALLHAT authors1 concluded
that chlorthalidone resulted in improved drug tolerance compared with lisinopril
because of the confounding drug use in the ACE inhibitor group. In fact, patients
randomized to chlorthalidone received diuretics 8% more often than patients
in the lisinopril group receiving ACE inhibitors and 2% more crossovers occurred
in the lisinopril group. In addition to the 10% difference in actual drug
usage, lisinopril was less effective in controlling the systolic blood pressure,
resulting in 2% more step 2 or 3 drugs used, compared with chlorthalidone.
Patients randomized to receive diuretics received the drugs more often than
patients randomized to receive lisinopril and ACE inhibitors, and more add-on
therapy (atenolol, reserpine, clonidine, and hydralazine) was needed in the
latter group. Thus, the decreased drug tolerance of lisinopril was likely
the result of increased usage of secondary agents with higher adverse effects.
Long-term Cardiovascular Consequences of Diuretics vs Calcium Channel
Blockers vs Angiotensin-Converting Enzyme Inhibitors. JAMA. 2003;289(16):2066. doi:10.1001/jama.289.16.2068-c