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Thiazide diuretics are a class of drugs commonly recommended as first‐line treatment for raised blood pressure because they significantly reduce death, stroke and heart attacks. This class includes bendrofluazide, chlorthalidone, cyclopenthiazide, hydrochlorothiazide, indapamide and metolazone. We asked by how much does this class of drugs lower blood pressure and whether there is a difference between individual drugs within the class. We searched the available scientific literature to find all the trials that had assessed this question. The data included in this review was up to date as of February 2014.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: May 29, 2014

Azilsartan medoxomil (AZL) is the most recently approved angiotensin receptor blocker (ARB) for treating patients with hypertension. A fixed-dose combination product with AZL and the thiazide-like diuretic chlorthalidone (CLD) is now available to treat individuals who require additional blood pressure lowering. For this review, a literature search was conducted using MEDLINE and the keywords and MeSH terms azilsartan, azilsartan medoxomil, chlorthalidone, thiazide, blood pressure and hypertension. References for retrieved articles were also scanned for relevant citations. No language restrictions were used. AZL is structurally related to candesartan and has been shown to provide more potent angiotensin receptor antagonism versus other ARBs. CLD is a thiazide-like diuretic with a longer half-life and greater blood pressure lowering efficacy than hydrochlorothiazide. The combination of AZL plus CLD has superior efficacy to other ARBs alone or in combination with hydrochlorothiazide based on extensive evaluation in clinical trials. This superior efficacy is not offset by a large imbalance in clinically important adverse events.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2014

This review and network meta-analysis concluded that chlortalidone was better than hydrochlorothiazide for preventing cardiovascular events, in patients with hypertension. There were concerns about the limited search, poor reporting, and indirect analysis, but the results and conclusions are likely to be reliable.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2012

This guideline has been developed to advise on supporting people with dementia and their carers in health and social care. The guideline recommendations have been developed by a multidisciplinary team of health and social care professionals, a person with dementia, carers and guideline methodologists after careful consideration of the best available evidence. It is intended that the guideline will be useful to practitioners and service commissioners in providing and planning high-quality care for those with dementia while also emphasising the importance of the experience of care for people with dementia and carers.

NICE Clinical Guidelines - National Collaborating Centre for Mental Health (UK).

Version: 2007

NICE first issued guidance for the management of hypertension in primary care in 2004. This was followed by a rapid update of the pharmacological treatment chapter of the guideline in 2006. The current partial update of the hypertension guideline is in response to the regular five year review cycle of existing NICE guidance. It began with a scoping exercise which identified key areas of the existing guideline for which new evidence had emerged that was likely to influence or change existing guideline recommendations.

NICE Clinical Guidelines - National Clinical Guideline Centre (UK).

Version: August 2011

Beta blockers inhibit the chronotropic, inotropic, and vasoconstrictor responses to the catecholamines, epinephrine, and norepinephrine. Beta blockers differ in their duration of effect (3 hours to 22 hours), the types of beta receptors they block (β1-selective or β1/β2-nonselective), whether they are simultaneously capable of exerting low level heart rate increases (intrinsic sympathomimetic activity [ISA]), and in whether they provide additional blood vessel dilation effects by also blocking alpha-1 receptors. All beta blockers are approved for the treatment of hypertension. Other US Food and Drug Administration-approved uses are specific to each beta blocker and include stable and unstable angina, atrial arrhythmias, bleeding esophageal varices, coronary artery disease, asymptomatic and symptomatic heart failure, migraine, and secondary prevention of post-myocardial infarction. The objective of this review was to evaluate the comparative effectiveness and harms of beta blockers in adult patients with hypertension, angina, coronary artery bypass graft, recent myocardial infarction, heart failure, atrial arrhythmia, migraine or bleeding esophageal varices.

Drug Class Reviews - Oregon Health & Science University.

Version: July 2009

The aim of this investigation is to find out the extent to which the benefit of antihypertensive drugs is dependent on the choice of the first-line drug in the treatment of essential hypertension.

Institute for Quality and Efficiency in Health Care: Executive Summaries [Internet] - Institute for Quality and Efficiency in Health Care (IQWiG).

Version: July 15, 2009

Hypertension in children can be associated with adverse health outcomes and may persist into adulthood, where it presents a significant personal and public health burden. Screening asymptomatic children has the potential to detect hypertension at earlier stages, so that interventions can be initiated which, if effective, could reduce the adverse health effects of childhood hypertension in children and adults.

Evidence Syntheses - Agency for Healthcare Research and Quality (US).

Version: February 2013

Multimorbidity is usually defined as when an individual has two or more long-term conditions. Measuring the prevalence of multimorbidity is not straightforward since this will vary depending on which conditions are counted, but all recent studies show that multimorbidity is common, becomes more common as people age, and is more common in people from less affluent areas. A recent large UK based study found that 42% of the population had at least one of the 40 conditions counted, and 23% had multimorbidity. Two-thirds of people aged 65 years or over had multimorbidity, and 47% had three or more conditions. People living in the most deprived areas had double the rate of multimorbidity in middle age than those living in the most affluent areas. Put another way, they developed multimorbidity 10-15 years before their more affluent peers. The recognition of multimorbidity associated with socioeconomic depreivation is particularly important as NHS England has a legal duty to have regard to the need to reduce health inequalities. Whereas rates of multimorbidity in older people was largely due to higher rates of physical conditions, in the less affluent multimorbidity was due to combinations of physical and mental health conditions was common.

NICE Guideline - National Guideline Centre (UK).

Version: September 2016

This guideline covers the physical, emotional, social and spiritual elements of end of life care, and focuses on improving the child or young person’s quality of life and supporting their family and carers. There are, for instance, recommendations on managing distressing symptoms and providing care and bereavement support after death. Recommendations have also been made about how services should be delivered. The guideline is aimed at all providers of paediatric end of life care, whatever their level of practise, and also for children and young people with life-limiting conditions and their parents or carers.

NICE Guideline - National Guideline Alliance (UK).

Version: December 2016

This clinical guideline concerns the management of hypertensive disorders in pregnancy and their complications from preconception to the postnatal period. For the purpose of this guideline, ‘pregnancy’ includes the antenatal, intrapartum and postpartum (6 weeks after birth) periods. The guideline has been developed with the aim of providing guidance in the following areas: information and advice for women who have chronic hypertension and are pregnant or planning to become pregnant; information and advice for women who are pregnant and at increased risk of developing hypertensive disorders of pregnancy; management of pregnancy with chronic hypertension; management of pregnancy in women with gestational hypertension; management of pregnancy for women with pre-eclampsia before admission to critical care level 2 setting; management of pre-eclampsia and its complications in a critical care setting; information, advice and support for women and healthcare professionals after discharge to primary care following a pregnancy complicated by hypertension; care of the fetus during pregnancy complicated by a hypertensive disorder.

NICE Clinical Guidelines - National Collaborating Centre for Women's and Children's Health (UK).

Version: August 2010

Renal denervation refers to catheter-based radiofrequency ablation of renal sympathetic nerves, which may reduce blood pressure in patients with resistant hypertension, but data on its effectiveness are conflicting.

Technology Assessments - Agency for Healthcare Research and Quality (US).

Version: July 2016

Metformin is a biguanide oral hypoglycemic used primarily for treating type 2 diabetes mellitus (T2D). Evidence suggests that, in addition to improving glycemic control, metformin is associated with improved all-cause and cardiovascular mortality and decreased risk of some cancers. However, clinicians have been advised by the U.S. Food and Drug Administration (FDA) to exercise caution in prescribing metformin to individuals with chronic kidney disease (CKD), unstable congestive heart failure (CHF), chronic liver disease (CLD), and older age due to perceived risk of side effects, including lactic acidosis (LA).

Evidence-based Synthesis Program - Department of Veterans Affairs (US).

Version: September 2016

Hypertension is a very common chronic illness in the United States and among Veterans. Use of antihypertensive medications can lower the risk of cardiovascular disease, cerebrovascular disease, renal disease, and death. The most beneficial blood pressure targets for patients of specific age groups, however, has been a topic of some debate and controversy, stemming from concerns that the ratio of benefit to harm of a given blood pressure level may vary with age. In 2014, the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (previously JNC-FG8, referred to in this report as JNC-BP) published new guidelines for the treatment of hypertension, as well as a new treatment goal for older individuals (over age 60) for systolic blood pressure (SBP) of < 150 mm Hg rather than < 140 mm Hg. The new goal for those over 60 years of age has been very controversial; the issue of the appropriate (safest and most beneficial) goal for older people has been debated among experts with viewpoints supporting both higher and lower treatment goals. The objectives of this review are to examine the benefits and harms of differing blood pressure targets among adults over age 60.

Evidence-based Synthesis Program - Department of Veterans Affairs (US).

Version: April 2016

To evaluate the evidence on screening and treating asymptomatic adults for carotid artery stenosis (CAS) for the U.S. Preventive Services Task Force (USPSTF).

Evidence Syntheses - Agency for Healthcare Research and Quality (US).

Version: July 2014

This study found evidence to support the use of annual screening to identify the development of early kidney disease in patients with diabetes, which is consistent with current UK guidelines. For type 1 diabetes, the costs of annual screening are well within the accepted level of cost-effectiveness, and, for patients with type 2 diabetes, annual screening is even more cost-effective.

Health Technology Assessment - NIHR Journals Library.

Version: February 2014

The Renal National Service Framework (NSF), and the subsequent NICE Clinical Practice Guideline for early identification and management of adults with chronic kidney disease (CKD) in primary and secondary care (CG73), served to emphasise the change in focus in renal medicine from treatment of established kidney disease to earlier identification and prevention of kidney disease.

NICE Clinical Guidelines - National Clinical Guideline Centre (UK).

Version: July 2014

Type 1 diabetes affects over 370,000 adults in the UK, representing approximately 10% of adults diagnosed with diabetes. Given the complexity of its treatment regimens, successful outcomes depend, perhaps more than with any other long-term condition, on full engagement of the adult with type 1 diabetes in life-long day-by-day self-management. In order to support this, the health service needs to provide informed, expert support, education and training as well as a range of other more conventional biomedical services and interventionsfor the prevention and management of long term complications and disability.

NICE Guideline - National Clinical Guideline Centre (UK).

Version: August 2015

This guidance is a partial update of National Institute for Health and Care Excellence (NICE) clinical guideline 40 (published October 2006) and will replace it.

NICE Clinical Guidelines - National Collaborating Centre for Women's and Children's Health (UK).

Version: September 2013

This review assessed evidence for interventions aimed at preventing or delaying the onset of age-related cognitive decline, mild cognitive impairment (MCI), or clinical Alzheimer’s-type dementia (CATD).

Comparative Effectiveness Reviews - Agency for Healthcare Research and Quality (US).

Version: March 2017

Systematic Reviews in PubMed

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