The effects of diuretic deprescribing in adult patients: A systematic review to inform an evidence-based diuretic deprescribing guideline.
deprescribing
diuretics
heart failure
hypertension
patient‐relevant outcomes
systematic review
Journal
British journal of clinical pharmacology
ISSN: 1365-2125
Titre abrégé: Br J Clin Pharmacol
Pays: England
ID NLM: 7503323
Informations de publication
Date de publication:
08 Aug 2024
08 Aug 2024
Historique:
revised:
01
07
2024
received:
21
03
2024
accepted:
03
07
2024
medline:
9
8
2024
pubmed:
9
8
2024
entrez:
8
8
2024
Statut:
aheadofprint
Résumé
In this systematic review, we report on the effects of diuretic deprescribing compared to continued diuretic use. We included clinical studies reporting on outcomes such as mortality, heart failure recurrence, tolerability and feasibility. We assessed risk of bias and certainty of the evidence using the GRADE framework. We included 25 publications from 22 primary studies (15 randomized controlled trials; 7 nonrandomized studies). The mean number of participants in the deprescribing groups was 35, and median/mean age 64 years. In patients with heart failure, there was no clear evidence that diuretic deprescribing was associated with increased mortality compared to diuretic continuation (low certainty evidence). The risk of cardiovascular composite outcomes associated with diuretic deprescribing was inconsistent (studies showing lower risk for diuretic deprescribing, or comparable risk with diuretic continuation; very low certainty evidence). The effect on heart failure recurrence after diuretic deprescribing in patients with diuretics for heart failure, and of hypertension in patients with diuretics for hypertension was inconsistent across the included studies (low certainty evidence). In patients with diuretics for hypertension, diuretic deprescribing was well tolerated (moderate certainty evidence), while in patients with diuretics for heart failure, deprescribing diuretics can result in complaints of peripheral oedema (very low certainty evidence). The overall risk of bias was generally high. In summary, this systematic review suggests that diuretic discontinuation could be a safe and feasible treatment option for carefully selected patients. However, there isa lack of high-quality evidence on its feasibility, safety and tolerability of diuretic deprescribing, warranting further research.
Types de publication
Journal Article
Review
Langues
eng
Sous-ensembles de citation
IM
Informations de copyright
© 2024 The Author(s). British Journal of Clinical Pharmacology published by John Wiley & Sons Ltd on behalf of British Pharmacological Society.
Références
Savarese G, Becher PM, Lund LH, Seferovic P, Rosano GMC, Coats AJS. Global burden of heart failure: a comprehensive and updated review of epidemiology. Cardiovasc Res. 2022;118(17):3272‐3287. doi:10.1093/cvr/cvac013
Sheppard JP, Koshiaris C, Stevens R, et al. The association between antihypertensive treatment and serious adverse events by age and frailty: a cohort study. PLoS Med. 2023;20(4):e1004223. doi:10.1371/journal.pmed.1004223
Simonavicius J, Knackstedt C, Brunner‐La Rocca HP. Loop diuretics in chronic heart failure: how to manage congestion? Heart Fail Rev. 2019;24(1):17‐30. doi:10.1007/s10741‐018‐9735‐7
Ravioli S, Bahmad S, Funk GC, Schwarz C, Exadaktylos A, Lindner G. Risk of electrolyte disorders, syncope, and falls in patients taking thiazide diuretics: results of a cross‐sectional study. Am J Med. 2021;134(9):1148‐1154. doi:10.1016/j.amjmed.2021.04.007
Barber J, McKeever TM, McDowell SE, et al. A systematic review and meta‐analysis of thiazide‐induced hyponatraemia: time to reconsider electrolyte monitoring regimens after thiazide initiation? Brit J Clin Pharmacol. 2015;79(4):566‐577. doi:10.1111/bcp.12499
Sztramko R, Chau V, Wong R. Adverse drug events and associated factors in heart failure therapy among the very elderly. Can Geriatr J. 2011;14(4):79‐92. doi:10.5770/cgj.v14i4.19
Mertens B, Hias J, Hellemans L, et al. Drug‐related hospital admissions in older adults: comparison of the Naranjo algorithm and an adjusted version of the Kramer algorithm. Eur Geriatr Med. 2022;13(3):567‐577. doi:10.1007/s41999‐022‐00623‐7
Aubert CE, Rodondi N, Netzer S, et al. Predictors of 1‐year drug‐related admissions in older multimorbid hospitalized adults. J Am Geriatr Soc. 2022;70(5):1510‐1516. doi:10.1111/jgs.17667
Hendriksen LC, van der Linden PD, Lagro‐Janssen ALM, et al. Sex differences associated with adverse drug reactions resulting in hospital admissions. Biol Sex Differ. 2021;12(1):34. doi:10.1186/s13293‐021‐00377‐0
Hill‐Taylor B, Walsh KA, Stewart S, Hayden J, Byrne S, Sketris IS. Effectiveness of the STOPP/START (screening tool of older Persons' potentially inappropriate prescriptions/screening tool to alert doctors to the right treatment) criteria: systematic review and meta‐analysis of randomized controlled studies. J Clin Pharm Ther. 2016;41(2):158‐169. doi:10.1111/jcpt.12372
ter Maaten JM, Martens P, Damman K, et al. Higher doses of loop diuretics limit uptitration of angiotensin‐converting enzyme inhibitors in patients with heart failure and reduced ejection fraction. Clin Res Cardiol. 2020;109(8):1048‐1059. doi:10.1007/s00392‐020‐01598‐w
Mullens W, Verbrugge FH, Nijst P, Tang WHW. Renal sodium avidity in heart failure: from pathophysiology to treatment strategies. Eur Heart J. 2017;38(24):1872‐1882. doi:10.1093/eurheartj/ehx035
Okoye C, Mazzarone T, Cargiolli C, Guarino D. Discontinuation of loop diuretics in older patients with chronic stable heart failure: a narrative review. Drugs Aging. 2023;40(11):981‐990. doi:10.1007/s40266‐023‐01061‐1
Oshima K, Kohsaka S, Koide K, Yoshikawa T. Reducing the dose of diuretics for heart failure patients: how low can it Go? Cardiology. 2009;114(2):89. doi:10.1159/000216583
Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the heart failure association (HFA) of the ESC. Eur J Heart Fail. 2016;18(8):891‐975. doi:10.1002/ejhf.592
Mancia G, Kreutz R, Brunström M, et al. 2023 ESH guidelines for the management of arterial hypertension the task force for the management of arterial hypertension of the European Society of Hypertension Endorsed by the International Society of Hypertension (ISH) and the European renal association (ERA). J Hypertens. 2023;41(12):1874‐2071. doi:10.1097/HJH.0000000000003480
Fosnight S, Soric MM, Smearman J, et al. Investigation into potentially inappropriate prescribing patterns of loop diuretics in a nationally representative outpatient population. Am J Ther. 2023;31(4):e347‐e355. doi:10.1097/MJT.0000000000001644
Damoiseaux‐Volman BA, Medlock S, Raven K, et al. Potentially inappropriate prescribing in older hospitalized Dutch patients according to the STOPP/START criteria v2: a longitudinal study. Eur J Clin Pharmacol. 2021;77(5):777‐785. doi:10.1007/s00228‐020‐03052‐2
Anderson TS, Steinman MA. Antihypertensive prescribing cascades as high‐priority targets for deprescribing. JAMA Intern Med. 2020;180(5):651‐652. doi:10.1001/jamainternmed.2019.7082
Vardeny O, Claggett B, Kachadourian J, et al. Reduced loop diuretic use in patients taking sacubitril/valsartan compared with enalapril: the PARADIGM‐HF trial. Eur J Heart Fail. 2019;21(3):337‐341. doi:10.1002/ejhf.1402
Wachter R, Fonseca AF, Balas B, et al. Real‐world treatment patterns of sacubitril/valsartan: a longitudinal cohort study in Germany. Eur J Heart Fail. 2019;21(5):588‐597. doi:10.1002/ejhf.1465
Shirakabe A, Matsushita M, Kiuchi K, et al. Empagliflozin administration can decrease the dose of loop diuretics and prevent the exacerbation of renal tubular injury in patients with compensated heart failure complicated by diabetes. Circulation Rep. 2020;2(10):565‐575. doi:10.1253/circrep.CR‐20‐0041
Kim SJ, Kim BJ, Im SI, Kim HS, Heo JH. Effects of empagliflozin on diuretics reduction in outpatient heart failure patients. Int J Heart Fail. 2022;4(4):183‐192. doi:10.36628/ijhf.2022.0009
Kapelios CJ, Laroche C, Crespo‐Leiro MG, et al. Association between loop diuretic dose changes and outcomes in chronic heart failure: observations from the ESC‐EORP heart failure Long‐term registry. Eur J Heart Fail. 2020;22(8):1424‐1437. doi:10.1002/ejhf.1796
van Poelgeest E, Seppala L, Bahat G, et al. Optimizing pharmacotherapy and deprescribing strategies in older adults living with multimorbidity and polypharmacy: EuGMS SIG on pharmacology position paper. Eur Geriatr Med. 2023;14(6):1195‐1209. doi:10.1007/s41999‐023‐00872‐0
Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. PLoS Med. 2021;18(3):e1003583. doi:10.1371/journal.pmed.1003583
Sterne JAC, Savovic J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ‐Brit Med J. 2019;366. doi:10.1136/bmj.l4898
Sterne JAC, Hernán MA, Reeves BC, et al. ROBINS‐I: a tool for assessing risk of bias in non‐randomised studies of interventions. BMJ‐Brit Med J. 2016;355. doi:10.1136/bmj.i4919
Murad MH, Mustafa RA, Schunemann HJ, Sultan S, Santesso N. Rating the certainty in evidence in the absence of a single estimate of effect. Evid Based Med. 2017;22(3):85‐87. doi:10.1136/ebmed‐2017‐110668
Romano G, Vitale G, Bellavia D, Agnese V, Clemenza F. Is diuretic withdrawal safe in patients with heart failure and reduced ejection fraction? A retrospective analysis of our outpatient cohort. Eur J Intern Med. 2017;42:E11‐E13. doi:10.1016/j.ejim.2017.03.025
van Kraaij DJW, Jansen RWMM, Gribnau FWJ, Hoefnagels WHL. Use of diuretics and opportunities for withdrawal in a Dutch nursing home population. Neth J Med. 1998;53(1):20‐26. doi:10.1016/S0300‐2977(98)00053‐9
Kapelios CJ, Kaldara E, Ntalianis A, et al. Lowering furosemide dose in stable chronic heart failure patients with reduced ejection fraction is not accompanied by decompensation: a randomized study. Int J Cardiol. 2014;177(2):690‐692. doi:10.1016/j.ijcard.2014.09.156
Martens P, Verbrugge FH, Nijst P, Dupont M, Mullens W. Changes in loop diuretic dose and outcome after cardiac resynchronization therapy in patients with heart failure and reduced left ventricular ejection fractions. Am J Cardiol. 2017;120(2):267‐273. doi:10.1016/j.amjcard.2017.04.021
Nuzzi V, Cannatà A, Pellicori P, et al. Diuretic dose trajectories in dilated cardiomyopathy: prognostic implications. Clin Res Cardiol. 2023;112(3):454. doi:10.1007/s00392‐022‐02133‐9
Walma EP, Hoes AW, van Dooren C, Prins A, van der Does E. Withdrawal of long term diuretic medication in elderly patients: a double blind randomised trial. BMJ‐Brit Med J. 1997;315(7106):464‐468. doi:10.1136/bmj.315.7106.464
van Kraaij DJW, Jansen RWMM, Sweep FCGJ, Hoefnagels WHL. Neurohormonal effects of furosemide withdrawal in elderly heart failure patients with normal systolic function. Eur J Heart Fail. 2003;5(1):47‐53. doi:10.1016/S1388‐9842(02)00205‐2
van Kraaij DJW, Jansen RWMM, Bouwels LHR, Hoefnagels WHL. Furosemide withdrawal improves postprandial hypotension in elderly patients with heart failure and preserved left ventricular systolic function. Arch Intern Med. 1999;159(14):1599‐1605. doi:10.1001/archinte.159.14.1599
Rohde LE, Rover MM, Neto JAF, et al. Short‐term diuretic withdrawal in stable outpatients with mild heart failure and no fluid retention receiving optimal therapy: a double‐blind, multicentre, randomized trial. Eur Heart J. 2019;40(44):3605‐3612. doi:10.1093/eurheartj/ehz554
Chen YJ, Qiu ZP, Jiang J, et al. Outcomes of spironolactone withdrawal in dilated cardiomyopathy with improved ejection fraction. Front Cardiovasc Med. 2021;8:8. doi:10.3389/fcvm.2021.725399
van Kraaij DJ, Jansen RW, Bouwels LH, Go RI, Verheugt FW, Hoefnagels WH. Use of Valsalva's maneuver to detect early recurrence of congestive heart failure in a randomized trial of furosemide withdrawal in older patients. J am Geriatr Soc. 1999;47(11):1384‐1385. doi:10.1111/j.1532‐5415.1999.tb07448.x
Fudim M, O'Connor CM, Mulder H, et al. Loop diuretic adjustments in patients with chronic heart failure: Insights from HF‐ACTION. Am Heart J. 2018;205:133‐141. doi:10.1016/j.ahj.2018.06.017
van Kraaij DJW, Jansen RWMM, Bouwels LHR, Gribnau FWJ, Hoefnagels WHL. Furosemide withdrawal in elderly heart failure patients with preserved left ventricular systolic function. Am J Cardiol. 2000;85(12):1461‐1466. doi:10.1016/S0002‐9149(00)00795‐5
Brijker F, Heijdra YF, van den Elshout FJJ, Folgering HTM. Discontinuation of furosemide decreases Pacoin patients with COPD. Chest. 2002;121(2):377‐382. doi:10.1378/chest.121.2.377
Maland LJ, Lutz LJ, Castle CH. Effects of withdrawing diuretic therapy on blood‐pressure in mild hypertension. Hypertension. 1983;5(4):539‐544. doi:10.1161/01.HYP.5.4.539
Freis ED, Thomas JR, Fisher SG, et al. Effects of reduction in drugs or dosage after Long‐term control of systemic hypertension. Am J Cardiol. 1989;63(11):702‐708. doi:10.1016/0002‐9149(89)90255‐5
Sheppard JP, Lown M, Burt J, et al. Blood pressure changes following antihypertensive medication reduction, by drug class and dose chosen for withdrawal. Exploratory Analysis of Data from the OPTiMISE Trial Front Pharmacol. 2021;12:12. doi:10.3389/fphar.2021.619088
Takata Y. Which antihypertensive drug to withdraw and when. Cardiol Board Rev. 1993;10:50.
Upadhya B, Lovato LC, Rocco M, et al. Heart failure prevention in older patients using intensive blood pressure reduction potential role of diuretics. Jacc‐Heart Fail. 2019;7(12):1032‐1041. doi:10.1016/j.jchf.2019.08.018
Moonen JE, Foster‐Dingley JC, de Ruijter W, van der Grond J, de Craen AJ, van der Mast RC. Effect of discontinuation of antihypertensive medication on orthostatic hypotension in older persons with mild cognitive impairment: the DANTE study Leiden. Age Ageing. 2016;45(2):249‐255. doi:10.1093/ageing/afv199
de Jonge JW, Knottnerus JA, van Zutphen WM, de Bruijne GA, Struijker Boudier HA. Short term effect of withdrawal of diuretic drugs prescribed for ankle oedema. BMJ. 1994;308(6927):511‐513. doi:10.1136/bmj.308.6927.511
Burr ML, King S, Davies HE, Pathy MS. The effects of discontinuing long‐term diuretic therapy in the elderly. Age Ageing. 1977;6(1):38‐45. doi:10.1093/ageing/6.1.38
Myers MG, Weingert ME, Fisher RH, Gryfe CI, Shulman HS. Unnecessary diuretic therapy in the elderly. Age Ageing. 1982;11(4):213‐221. doi:10.1093/ageing/11.4.213
Takata Y, Yoshizumi T, Ito Y, et al. Comparison of withdrawing antihypertensive therapy between diuretics and angiotensin converting enzyme‐inhibitors in essential hypertensives. Am Heart J. 1992;124(6):1574‐1580. doi:10.1016/0002‐8703(92)90075‐7
Page AT, Clifford RM, Potter K, Schwartz D, Etherton‐Beer CD. The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta‐analysis. Brit J Clin Pharmacol. 2016;82(3):583‐623. doi:10.1111/bcp.12975
Sirois C, Gosselin M, Laforce C, Gagnon ME, Talbot D. How does deprescribing (not) reduce mortality? A review of a meta‐analysis in community‐dwelling older adults casts uncertainty over claimed benefits. Basic Clin Pharmacol Toxicol. 2023;134(1):51‐62. doi:10.1111/bcpt.13921
Reeve E, Shakib S, Hendrix I, Roberts MS, Wiese MD. Review of deprescribing processes and development of an evidence‐based, patient‐centred deprescribing process. Br J Clin Pharmacol. 2014;78(4):738‐747. doi:10.1111/bcp.12386
van der Wardt V, Harrison JK, Welsh T, Conroy S, Gladman J. Withdrawal of antihypertensive medication: a systematic review. J Hypertens. 2017;35(9):1742‐1749. doi:10.1097/HJH.0000000000001405
Reeve E, Jordan V, Thompson W, et al. Withdrawal of antihypertensive drugs in older people. Cochrane Database Syst Rev. 2020;6(6):CD012572. doi:10.1002/14651858.CD012572.pub2
McNallan SM, Singh M, Chamberlain AM, et al. Frailty and healthcare utilization among patients with heart failure in the community. Jacc‐Heart Fail. 2013;1(2):135‐141. doi:10.1016/j.jchf.2013.01.002
Kapelios CJ, Malliaras K, Nanas JN. Dosing of loop diuretics in chronic heart failure: it's time for evidence. Eur J Heart Fail. 2016;18(10):1298. doi:10.1002/ejhf.619
Duong MH, Gnjidic D, McLachlan AJ, Sakiris MA, Goyal P, Hilmer SN. The prevalence of adverse drug reactions and adverse drug events from heart failure medications in frail older adults: a systematic review. Drugs Aging. 2022;39(8):631‐643. doi:10.1007/s40266‐022‐00957‐8
de Boer AR, Vaartjes I, Gohar A, et al. Heart failure with preserved, mid‐range, and reduced ejection fraction across health care settings: an observational study. ESC Heart Fail. 2022;9(1):363‐372. doi:10.1002/ehf2.13742
Martens P, Verbrugge FH, Boonen L, Nijst P, Dupont M, Mullens W. Value of routine investigations to predict loop diuretic down‐titration success in stable heart failure. Int J Cardiol. 2018;250:171‐175. doi:10.1016/j.ijcard.2017.10.018
Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥75 years a randomized clinical trial. JAMA‐J Am Med Assoc. 2016;315(24):2673‐2682. doi:10.1001/jama.2016.7050
Reeve E, Gnjidic D, Long J, Hilmer S. A systematic review of the emerging definition of 'deprescribing' with network analysis: implications for future research and clinical practice. Brit J Clin Pharmacol. 2015;80(6):1254‐1268. doi:10.1111/bcp.12732
Bayliss EA, Albers K, Gleason K, et al. Recommendations for outcome measurement for deprescribing intervention studies. J Am Geriatr Soc. 2022;70(9):2487‐2497. doi:10.1111/jgs.17894
Fried TR, Tinetti ME, Iannone L, O'Leary JR, Towle V, Van Ness PH. Health outcome prioritization as a tool for decision making among older persons with multiple chronic conditions. Arch Intern Med. 2011;171(20):1854‐1856. doi:10.1001/archinternmed.2011.424