Study Shows Amlodipine Beats Thiazide-Based Treatment, Especially in Non-Obese Patients

In a randomized trial of patients with hypertension, amlodipine was superior to thiazides in normal weight than obese patients, whereas the treatments were approximately equal in obese patients with hypertension, according to a study published on Dec. 5 in The Lancet.

A subanalysis of ACCOMPLISH, an international, randomized, double-blind, two-arm trial, the study grouped 11,482 patients according to three BMI categories. All patients were randomized to amlodipine plus benazapril vs. hydrochlorothiazide plus benazepril. In obese individuals, primary event rates were similar with both benazepril and hydrochlorothiazide and benazepril and amlodipine, but rates were significantly lower with benazepril and amlodipine in normal weight patients (0 • 57, p=0 • 0037) and overweight patients (hazard ratio 0 • 76, p=0 • 0369) whereas there was just a trend toward benefit in the obese patients hazard 0.89, p=0.31.

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"Higher cardiovascular event rates in lean patients reported in hypertension clinical trials might have reflected the types of antihypertensive treatments that were used," notes Michael Weber, MD, FACC, from the State University of New York's Downstate Medical Center who led the research. "Diuretic-based regimens seem to be a reasonable choice in obese patients in whom excess volume provides a rationale for this type of treatment, but thiazides are clearly less protective against cardiovascular events in patients who are lean." However, he cautions, "our observations might not be fully generalizable to all types of treatments…since they were driven predominantly by findings in one (the diuretic-based) of our two treatment groups."

A related editorial comment raised questions about the authors' conclusions that diuretic-based regiments are a reasonable choice in obese patients. "On the contrary, we surmise that thiazide diuretics are contraindicated in obesity, relatively speaking. If the indication is hypertension, amlodipine-based treatments should be used irrespective of body size," note the authors of the editorial.

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