Diuretics older people

Starting doses of ACE inhibitors should be low, with even lower doses started in patients at risk for orthostatic hypotension. Acute hypotension may occur at the onset on ACE inhibitor therapy. Patients who are sodium- or volume-depleted, in heart failure exacerbation, very elderly, or on concurrent vasodilators or diuretics are at high risk for this effect (see the Hypertension in Older People and Patients at Risk for Orthostatic Hypotension sections under Special Populations ). It is important to start with half the normal dose of an ACE inhibitor for all patients with these risk factors and to use slow dose titration. The risk of serious adverse reactions overah can be decreased approximately 50% by using a 6-week time interval between dose increases versus a 2-week interval. ... 

Thiazide diuretics work by inhibiting sodium and chloride ion transport in the distal convoluted tubule of the kidney and therefore limit water reabsorption. Thiazides are particularly recommended in older people. A commonly used example of this type of diuretic is bendroflumethiazide. 

Q4 For young people with essential hypertension, either a beta-blocker fi-blocker) or an ACE inhibitor is recommended. For older patients, the medication of choice for hypertension is either a diuretic or calcium channel blocker. 

The best overall evidence of the safety of diuretics in old people comes from the large-scale outcome trials in hypertensive patients (11,13,15,17,18). These studies in over 10000 subjects aged over 60 years showed clearly that thiazide-based treatment reduces the risk of stroke, coronary heart disease events, and cardiovascular events in older hypertensive patients. A meta-analysis (163) of randomized trials lasting at least 1 year and involving 16164 individuals aged at least 60 years showed that diuretics were superior to beta-blockers with regard to all endpoints (stroke, coronary heart disease events, cardiovascular mortality, and all-cause mortality). The beneficial effects noted in these trials should dispel any doubts about the safety and efficacy of diuretics in old people. 

People at greatest risk for nephrotoxicity have chrmiic kidney disease (CKD), hepatic disease with ascites, decompensated cOTigestive heart failure, intravascular volume depletion, or systemic lupus erythematosus (Perazella 2005). Additional risk factors include atherosclerotic cardiovascular disease and concurrent diuretic therapy. The elderly are also at higher risk due to interaction of prevalent medical problems, multiple drug therapies, and reduced renal hemodynamics. NS AID use in patients older than 65 years may increase the risk of AKI by up to 58% (Griffin et al. 2000). Combined NSAID or COX-2 inhibitor and ACEI or ARB therapy is also a concern and should be avoided in high risk patients. 

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