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Posts Tagged ‘diuretics’

                                                 It is now mandatory for all  journals  to declare the  conflict  of interest by the authors  who are involved in medical research .The purpose apparently is to make all transactions or links  between the researchers and their funding agencies transparent .Even major journals  do not go beyond this . Some ensure it , to appear in the first page of  the article.

 What does the the journals tend to  convey to the reader by publishing the conflicts of interest ?

  •  Does it  mean the article in question  may have a bias or indeed have a bias  ?  and readers are warned  hereby !
  •  Do they send across a message  that the  article may not be really a genuine one and the judgement is left to the the consumers of the articles ?

How often a journal article is rejected purely on the basis of  conflicts of interest ?

Most of  journal articles are rejected  for poor methodology, statistical analysis and so forth .We don’t know how often a paper is rejected  due to a conflict issue per se.If this could happen ,bulk  of drug trials would face a torrid time from the editors.

Why , even the leading scientific  journals never indulge in grading the significance of the conflict ?

Here is an example .

accomplish

nejm1

The much hyped drug trial on Hypertension “ACCOMPLISH”  was published in the  world’s most prestigious medical journal recently .It  left  it to the readers to  have their  own assessment  on the conflict issue.

  The consequence of not , grading and investigating  about the conflicts could have  serious  global health  implications both financially and academically .

This study was designed, formulated, completed and published  with a single hidden aim of neutralising the land mark trial  of ALLHAT which recommended diuretics as a first line drug in HT.Apparently diuretics are very  cheap  , effective  generic drugs.

 Is it a scientific rule  that  the  latest evidence  ,  should always prevail over the older evidence ?

No. Science can never have such a rule ! The question is how good and genuine is the evidence.
Just because an evidence is current , it does not  attain a scientific sanctity !

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Diuretics are the most commonly prescribed anti hypertensive agents.Thiazide diuretics which  was introduced many decades ago ,  lost popularity  in recent years ,  again got a second life after  the publication of ALLHAT trial recently. Now diuretics has become the  the drug of first choice in almost any hypertension unless any specific contraindication.

The most commonly used thaizide is hydrochlorthiazide ,and chlorthalidone.The blood pressure reducing effect is so consistent and smooth , all the currently popular molecules like ACE inhibitors and ARBs come with a combination with thiazide. While every one is clear diuretics are  effective anti hypertensive agent How it does is not clear.

How does a diuretic reduce blood pressure?

A. The exact mechanism is not clear. May not be uniformly effective in all patients  with HT.

B . Salt sensitive HT respond well to diuretics.

C. Volume correction /free water clearance might be a factor

D. Direct effect on vascular smoth muscle documented.The sodium transporter is blocked and  hence   calcium : sodium exchange is prevented .This depletes  intracellular calcium  in vascular smooth muscle cells .Less calcium for actin myosin interaction and hence vasodilatation

E. Thiazides combine well with all other antihypertensive drugs (ACEI, ARB, Beata blockers, calcium blockers)

F. Loop diuretics  like frusemide  can never be  a good antihypertensive agent.

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