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L. Michael Prisant; Albert A. Carr

Arch Intern Med. 1990;150(8):1758-1760.

Abstract
In Reply.—
Whether a diuretic added to a calcium antagonist or calcium antagonist added to diuretic is additive or synergistic is controversial and requires a well-designed study to answer the question.¹ Studies with diltiazem,² verapamil,³ and nifedipine⁴ in which a diuretic was added to a calcium antagonist have shown no additional hypotensive effects. However, two other studies have documented a further decrease in blood pressure with a diuretic.^5,6 The acute natriuresis may be dependent on the amount of sodium intake, whereas the antihypertensive effects are present regardless of the sodium intake.⁷ The continued natriuretic effect of calcium antagonists⁸ may be important in preventing fluid accumulation and reducing the hypotensive effect of an added diuretic. Recently, a multicenter factorial-design trial demonstrated that a slow-release formulation of diltiazem hydrochloride in combination with hydrochlorothiazide is additive.⁹ However, we are unaware of studies, other than ours,¹⁰ in which a calcium antagonist was added to a diuretic.

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