Reply to the letter regarding the article ‘Stopping mineralocorticoid receptor antagonists after hyperkalaemia: trial emulation in data from routine care’

Trevisan, Marco; Fu, Edouard L; Carrero, Juan Jesús

doi:10.1002/ejhf.2411

Cited by 2 publications

(1 citation statement)

References 4 publications

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“…Five observational studies 10,31,37,54,55 (n=30,385) on discontinuing spironolactone or eplerenone in community-dwelling HFpEF and HFrEF patients could not pool feasibility (I 2 =99%) and mortality (I 2 =98%). ADWE included 6% increased risk of major CV-events (e.g., CV-death, MI, stroke, HF) (HR 1.06, 95% CI 1.01 to 1.12, one-study, n=3,955, moderate-quality evidence) 54 .…”

Section: (V) Mineralocorticoid Receptor Antagonists (Mra)mentioning

confidence: 99%

The effect of down-titration and discontinuation of heart failure pharmacotherapy in older people: a systematic review and meta-analysis

Duong,

Gnjidic,

McLachlan

et al. 2024

Preprint

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Aim: To investigate if interventions to discontinue or down-titrate heart failure (HF)-pharmacotherapy are feasible and associated with risks in older people. Methods: A systematic review and meta-analysis were conducted according to PRISMA 2020 guidelines. Electronic databases were searched from inception to March 8th 2023. Randomised controlled trials (RCTs) and observational studies included people with HF, aged >50 years and who discontinued or down-titrated HF-pharmacotherapy. Outcomes were feasibility (whether discontinuation or down-titration of HF-pharmacotherapy was sustained at follow-up) and associated risks (mortality, hospitalisation, adverse drug withdrawal effects [ADWE]). Random-effects meta-analysis was performed when heterogeneity was not substantial (Higgins I2<70%). Sub-analysis by frailty status was conducted. Results: Six RCTs (536-participants) and 27 observational studies (810,499-participants) across six therapeutic classes were included, for 3-260 weeks follow-up. RCTs were conducted in patients presenting with stable HF. Down-titrating a renin-angiotensin system inhibitor (RASI) in patients with chronic kidney disease was 76% likely than continuation (Risk Ratio [RR] 1.76, 95%CI 1.14-2.73), with no difference in mortality (RR 0.64, 95%CI 0.30-1.64). Discontinuation of beta-blockers were feasible compared to continuation in preserved ejection fraction (RR 1.00, 95%CI 0.68-1.47). Participants were 25% likely to re-initiate discontinued diuretics (RR 0.75, 95%CI 0.66-0.86). Digoxin discontinuation was associated with 5.5-fold risk of hospitalisation compared to continuation. Worsening HF was the commonest ADWE. One observational study measured frailty but did not report outcomes by frailty status. Conclusions: The appropriateness and associated risks of down-titrating or discontinuing HF-pharmacotherapy in people aged >75 years is uncertain. Evaluation of outcomes by frailty status necessitates investigation.

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Section: (V) Mineralocorticoid Receptor Antagonists (Mra)mentioning

confidence: 99%

The effect of down-titration and discontinuation of heart failure pharmacotherapy in older people: a systematic review and meta-analysis

Duong,

Gnjidic,

McLachlan

et al. 2024

Preprint

View full text Add to dashboard Cite

show abstract

The effect of down‐titration and discontinuation of heart failure pharmacotherapy in older people: A systematic review and meta‐analysis

Duong,

Gnjidic,

McLachlan

et al. 2024

Brit J Clinical Pharma

View full text Add to dashboard Cite

The aim of this study was to investigate whether interventions to discontinue or down‐titrate heart failure (HF) pharmacotherapy are feasible and associated with risks in older people. A systematic review and meta‐analysis were conducted according to PRISMA 2020 guidelines. Electronic databases were searched from inception to 8 March 2023. Randomized controlled trials (RCTs) and observational studies included people with HF, aged ≥50 years and who discontinued or down‐titrated HF pharmacotherapy. Outcomes were feasibility (whether discontinuation or down‐titration of HF pharmacotherapy was sustained at follow‐up) and associated risks (mortality, hospitalization, adverse drug withdrawal effects [ADWE]). Random‐effects meta‐analysis was performed when heterogeneity was not substantial (Higgins I2 < 70%). Sub‐analysis by frailty status was conducted. Six RCTs (536 participants) and 27 observational studies (810 499 participants) across six therapeutic classes were included, for 3–260 weeks follow‐up. RCTs were conducted in patients presenting with stable chronic HF. Down‐titrating a renin‐angiotensin system inhibitor (RASI) in patients with chronic kidney disease was 76% more likely than continuation (risk ratio [RR] 1.76, 95% confidence interval [CI] 1.14–2.73), with no difference in mortality (RR 0.64, 95% CI 0.30–1.64). Discontinuation of beta‐blockers were feasible compared to continuation in preserved ejection fraction (RR 1.00, 95% CI 0.68–1.47). Participants were 25% more likely to re‐initiate discontinued diuretics (RR 0.75, 95% CI 0.66–0.86). Digoxin discontinuation was associated with 5.5‐fold risk of hospitalization compared to continuation. Worsening HF was the most common ADWE. One observational study measured frailty but did not report outcomes by frailty status. The appropriateness and associated risks of down‐titrating or discontinuing HF pharmacotherapy in people aged ≥75 years is uncertain. Evaluation of outcomes by frailty status necessitates investigation.

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Reply to the letter regarding the article ‘Stopping mineralocorticoid receptor antagonists after hyperkalaemia: trial emulation in data from routine care’

Cited by 2 publications

References 4 publications

The effect of down-titration and discontinuation of heart failure pharmacotherapy in older people: a systematic review and meta-analysis

The effect of down-titration and discontinuation of heart failure pharmacotherapy in older people: a systematic review and meta-analysis

The effect of down‐titration and discontinuation of heart failure pharmacotherapy in older people: A systematic review and meta‐analysis

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