Letters to the Editor

Readers react to ACP Internist's coverage, offering more resources for alcohol screening and ways to rethink first-line treatment for hypertension.

More resources available for alcohol screening

Your recent article on patients' alcohol consumption (“Taking a drink: what patients should know,” ACP Internist, January 2013) underscores the importance of brief screenings by primary care physicians in identifying and treating alcohol abuse.

Having spent more than 40 years in the practice of medicine, I can confirm that by asking just a few questions during a routine exam, a physician can quickly assess whether the patient is drinking alcohol as part of a normal healthy lifestyle, if counseling is needed to moderate the drinking behavior, or if abstention is the best advice. In fact, research shows that simply discussing your concerns about alcohol consumption can be effective in changing many patients' drinking behavior before problems can become chronic.

As your article pointed out, a key part of any discussion on alcohol should be educating patients about the definition of a standard drink. Cans, bottles and glassware come in a multitude of sizes and shapes, just as beer, wine and spirits brands come in a variety of different alcohol strengths.

Understanding the definition of a standard drink makes it easier for patients to calculate the amount of alcohol being consumed and, of importance, provides a benchmark for them to follow the advice of the federal dietary guidelines on alcohol consumption.

In my role as a medical advisor to the Distilled Spirits Council, I have worked with the industry and its partners in the health community to develop and compile materials that health professionals can use in discussing alcohol with their patients. The Educational Toolkit on Beverage Alcohol Consumption includes screening and brief intervention materials developed by the National Institute on Alcohol Abuse and Alcoholism, as well as informational tearsheets that patients can take home as a resource. Health professionals who want more information can go online.

Raymond Scalettar, MD, DSc, FACP
George Washington University Medical Center
Washington, D.C.

Rethinking first-line treatment for hypertension

Regarding the recent ACP InternistWeekly article “More than half of hypertensive black patients don't receive diuretics” (ACP InternistWeekly, Jan. 29, 2013), I wanted to remind readers that thiazide diuretics, while still suggested by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) as first-line treatment for essential hypertension, do not have well-founded support in the summary literature.

The current JNC recommendations were made from flawed extrapolations based on chlorthalidone, a more potent and longer-acting agent than hydrochlorothiazide. ALLHAT (the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) claimed that the inexpensive diuretic chlorthalidone achieved equivalent reductions in cardiovascular events (cardiovascular death and heart attack) as the nonthiazide antihypertensives lisinopril and amlodipine. There is, however, little evidence that hydrochlorothiazide at entry doses improves cardiovascular outcomes.

Further, the ACCOMPLISH (Avoiding Cardiovascular Events Through Combination Therapy in Patients Living With Systolic Hypertension) trial showed greater mortality with combination regimens of an angiotensin-converting enzyme (ACE) inhibitor plus hydrochlorothiazide than with an ACE inhibitor plus a calcium-channel blocker. A meta-analysis published in the February 2011 Journal of the American College of Cardiology (which included 14 studies that used 24-hour blood pressure monitoring) concluded, “The antihypertensive efficacy of [hydrochlorothiazide] in its daily dose of 12.5 to 25 mg as measured in head-to-head studies by ambulatory [blood pressure] measurement is consistently inferior to that of all other drug classes. Because outcome data at this dose are lacking, [hydrochlorothiazide] is an inappropriate first-line drug for the treatment of hypertension.”

I feel we should be mindful and aware of these data, keeping in mind that there may well be better first-line agents available for hypertension, regardless of patients' ethnicity.

Adam Smith, DO, ACP Member
Yale Health Center
New Haven, Conn.