Expert: Domenic Sica - 11/6/2009

Question
My wife is 49 and currently taking hydrochlorothiazide 25 mg (i belive), but is not very effective. Considering changing it to different type or combining it with different type. I understand there are four types: Diuretics, ACE Inhibitors, Calcium Channel Blockers, and Beta Blocker. Like to know which one is the most selected to avoid serious side effects such as effects on heart, kidney, liver, etc. or which is the safest to start with if given a choice in hierarchical order. Please provide your opinion in choice 1 through 4 based on the types mentioned above. One thing like to mention that ACE inhibitor works well at 5mg, but coughing is the problem. Can we try 2.5 or less and combined with hydrochlorothiazide? Can 2.5 minimize coughing? However, we still like to know your preference in hierarchical order. Thanks in advance.  

Answer
She is already on a diuretic so that is removed from the hierarchial order. If she has previously been on an ACE inhibitor and had cough then the cough would be likely to recur even on a lower dose of an ACE inhibitor. The best option would be an angiotensin-receptor blocker since it works similarly to an ACE inhibitor but is without a cough. If you opt out from an angiotensin receptor blocker then of the two choices you offer (beta blocker or calcium channel blocker) we usual make a selection in the context of the patient. Thus, I am at a little bit of a disadvantage since I do not know your wife. One example is we would use a beta blocker in someone with an intrinsically high heart rate (> 80 beats/min). As to there being serious heart, kidney, and liver side-effects with these medications I am unaware of such with any of these medication classes.

Regards,

Domenic Sica, M.D.