Wednesday, December 03, 2008


It’s not the way science is supposed to work. You don’t go out and hype your results after they are published. A research publication should stand, in the arena of scientific discussion and critical examination, on its own merits. But that’s not the way the ALLHAT steering committee looked at things. From the moment of its publication the study was spun and promoted like the latest woo.
ALLHAT did change practice. Thiazide prescriptions increased following its publication, but apparently not enough, according to the New York Times, to suit the boosters:

“It should have more than doubled,” said Dr. Curt D. Furberg, a public health sciences professor at Wake Forest University who was the first chairman of the steering committee for the study, which was known by the acronym Allhat. “The impact was disappointing.”

What was the vested interest in hyping ALLHAT? Some of the lead investigators, together with the media, seeking to advance the premise that pharmaceutical industry marketing had set back the cause of science in the treatment of hypertension, saw the study as a gigantic “see we told you so.”

Sure there were lessons in ALLHAT for the treatment of hypertension but the hype surrounding the study distracted us from a reasoned critical analysis of the findings. The message of the promoters, that thiazide diuretics were, plainly and simply, the starting drugs of choice for hypertension, went way beyond the study findings. There were serious concerns about the design, execution and interpretation of ALLHAT which I won’t belabor here. DB dealt with them in his blog as I did in these pages.

Some time ago on I cited concerns about the metabolic hazards of thiazides and a documented risk of sudden cardiac death. A recent meta-analysis, showing a similar trend towards increased sudden death, added to the concern. The senior investigator, renowned hypertension expert John Oates, said:

“If it's true, it's probably the largest adverse effect in the history of modern pharmacology. The number of individuals affected over the last 50 years would be staggering.”

The trend, while coming short of statistical significance, would be enough for the media to blow a new proprietary drug out of the water. The New York Times was silent.

Although thiazides, as I explained here, do have a very important role in the treatment of hypertension, the notion that thiazide monotherapy is the unequivocal first step in hypertension treatment was not supported by ALLHAT and now, we know, is just plain wrong.

1 comment:

Anonymous said...

We believe also monotherapy with only diuretic -whatever the type- is not enough. I checked also your post on last September. it is informative