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The Impact of Antihypertensive Medications on Bone Mineral Density and Fracture Risk

  • Hypertension (DS Geller and DL Cohen, Section Editors)
  • Published:
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Abstract

Purpose of Review

This review summarizes the impact of thiazide diuretics on fracture risk in older hypertensive individuals.

Recent Findings

We performed a post hoc evaluation of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial, a randomized, prospective, double blind hypertension study comparing a thiazide-like diuretic, a calcium channel blocker (CCB), and an angiotensin converting enzyme inhibitor (ACEi). We examined the risk of hip and pelvic fractures during the in-trial period (n = 22,180 participants; mean 4.9-year follow-up) and during the post-trial period using national data bases (n = 16,622 participants) (mean total follow-up 7.8 years). During the trial, participants randomized to the thiazide diuretic versus the CCB or the ACEi had a lower risk of fracture on adjusted analyses (HR 0.79 [95% CI, 0.63, 0.98], p = 0.04). Risk of fracture was significantly lower in participants randomized to the diuretic as compared to those randomized to the ACEi (HR 0.75 [95% CI, 0.58, 0.98]; p = 0.04), but not significantly different compared to the CCB (HR 0.87 [95% CI, 0.71, 1.09]; p = 0.17). Over the entire trial and post-trial period of follow-up, the cumulative incidence of fractures was non-significantly lower in participants assigned to the diuretic vs assignment to the ACEi or the CCB (HR 0.87 [0.74–1.03], p = 0.10) and versus each medication separately.

Summary

These findings establish a benefit for thiazide diuretic treatment for the prevention of fractures versus other commonly used antihypertensive medications using prospective, randomized data. The effects of the thiazide diuretic on bone appear to be long lasting.

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Abbreviations

ACEi:

Angiotensin converting enzyme inhibitor

ALLHAT:

Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial

Ang II:

Angiotensin two

ARB:

Angiotensin receptor blocker

BMD:

Bone mineral density

CCB:

Calcium channel blocker

CI:

Confidence interval

HR:

Hazard ratio

MONICA:

Multinational Monitoring of Trends and Determinants in Cardiovascular Disease Project

MrOS:

Osteoporotic Fractures in Men Study

OR:

Odds ratio

RAS:

Renin angiotensin system

RR:

Relative risk

SBP:

Systolic blood pressure

SD:

Standard deviation

SWAN:

Study of Women’s Health Across the Nation

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Acknowledgments

Sara L. Pressel reports grants from the National Heart, Lung, and Blood Institute. Karen L. Margolis reports grants from NIH.

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Authors and Affiliations

  1. Division of Endocrinology, Kaiser Permanente of Georgia, 3650 Steve Reynolds Blvd, Duluth, Atlanta, GA, 30096, USA

    Joshua I. Barzilay & Rachel Puttnam

  2. Coordinating Center for Clinical Trials, the University of Texas School of Public Health, Houston, TX, USA

    Barry R. Davis, Sara L. Pressel & Alokananda Ghosh

  3. HealthPartners Institute for Education and Research, Minneapolis, MN, USA

    Karen L. Margolis

  4. Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA

    Paul K. Whelton

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  1. Joshua I. Barzilay
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  2. Barry R. Davis
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Correspondence to Joshua I. Barzilay.

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Joshua I. Barzilay, Barry R. Davis, Sara L. Pressel, Alokananda Ghosh, Rachel Puttnam, Karen L. Margolis, and Paul K. Whelton declare that they have no conflict of interest.

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Barzilay, J.I., Davis, B.R., Pressel, S.L. et al. The Impact of Antihypertensive Medications on Bone Mineral Density and Fracture Risk. Curr Cardiol Rep 19, 76 (2017). https://doi.org/10.1007/s11886-017-0888-0

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