Ally Prebtani, MD: In someone with metabolic syndrome if they do not have diabetes and do not have any other compelling indications, you can choose any of the first-line agents: an angiotensin-converting enzyme (ACE) inhibitor, angiotensin-receptor blocker, a dihydropyridine calcium channel blocker, or a thiazide or thiazide-like diuretic. If they are >50 years, beta-blockers do not work as well. If they are <50 years, beta-blockers may also be chosen, but probably not as first-line therapy.
Your second question is, “Do beta-blockers or thiazide or thiazide-like diuretics cause diabetes?” They probably do not cause diabetes, but there is an association with thiazide diuretics. If you do not treat hypokalemia or if you make the patients hypokalemic, it is more likely they will have a higher risk of diabetes. But the evidence is not that strong.
Generally, we tend to use ACE inhibitors or calcium channel blockers, but thiazide diuretics are also fine, understanding some of the concerns.