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First-line drugs for hypertension
  1. Teck K Khong, DTB Associate Editor,
  2. Elizabeth Adeyeye
  1. Clinical Pharmacology Unit, St George's University of London, London, UK
  1. Correspondence to Dr Teck K Khong, Basic Medical Sciences, St George's University of London, London, UK; tkhong{at}

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Review of: Wright JM, Musini VM, Gill R. First-line drugs for hypertension (Review). Cochrane Database Syst Rev 2018;4:10.1002/14651858.CD001841.pub3.

Commentary by: Dr Elizabeth Adeyeye and Dr Teck Khong, Clinical Pharmacology, St George's, University of London, London, UK

Series Editor: Dr Teck Khong, DTB Associate Editor, Clinical Pharmacology, St George's, University of London, London, UK

Key learning points

  • There is high-quality evidence that morbidity and mortality were reduced with low-dose thiazide diuretics used first line compared with placebo in individuals with hypertension.

  • First‐line use of ACE inhibitors and calcium channel blockers may be similarly effective but the evidence was less robust.

  • First-line use of high-dose thiazides or beta-blockers was inferior to first-line low-dose thiazides.


Low-dose thiazide diuretics are effective in reducing morbidity and mortality associated with moderate-to-severe primary hypertension in adults.1


Hypertension remains a leading contributor to the burden of cardiovascular morbidity and mortality. This Cochrane systemic review has updated the original meta-analysis published in 2009 and the authors have assessed the outcomes associated with the main groups of antihypertensive drugs with the aim of establishing which should be used first-line.1 2 It did not include any new or additional studies and has confirmed the conclusions from the original review. The authors evaluated the evidence on morbidity and mortality when six of the …

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  • Funding This research has received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared. Refer to the online supplementary files to view the ICMJE form(s)

  • Provenance and peer review Commissioned; internally peer reviewed.