Withdrawal of long term diuretic medication in elderly patients: a double blind randomised trial

Walma, Edmond; Hoes, Arno W.; Dooren, C van; Prins, A; Does, E. van der

doi:10.1136/bmj.315.7106.464

Cited by 103 publications

(53 citation statements)

References 15 publications

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“…9,10 In contrast to the findings of Walma et al, 13 only a few of the patients in the present study restarted medication because of oedema; most restarted because of raised blood pressure.…”

Section: Comparison With Existing Literaturecontrasting

confidence: 54%

“…This is similar to the findings of Espeland et al, but lower than the 55% restarting patients reported by Aylett et al 9 Patients in the present study who used more than two cardiovascular drugs before stopping medication were more likely to restart medication within 6 months, which is in line with the review study of Nelson et al 14 However, these three latter studies concerned withdrawal from antihypertensive medication in normotensive patients, 9,13,14 whereas the present study re-evaluated the need for medication in both normotensive and (presumed) hypertensive patients.…”

Section: Comparison With Existing Literaturecontrasting

confidence: 35%

“…If patients decided to stop medication, the GP handed them a personalised medicationreduction schedule which, in complicated cases (such as polypharmacy), had been discussed with a pharmacist (for example, Box 1). Then, based on previous reports of long-term diuretic medication, 13 and a relapse of high blood pressure in the case of withdrawal, [8][9][10]14 an individual follow-up took place, which involved measuring blood pressure, serum lipid levels, and possible adverse events (for example, oedema, headache, high blood pressure, high cholesterol, feeling unwell, other problems). In cases of stopping diuretics, follow-up took place after 1, 2, 4, and 12 weeks, for stopping other antihypertensive medication after 4 and 12 weeks, and after stopping only statins after 12 weeks.…”

Section: Re-evaluationmentioning

confidence: 99%

See 2 more Smart Citations

Revised guidelines for cardiovascular risk management — time to stop medication? A practice-based intervention study

Duijn¹,

Belo²,

Blom³

et al. 2011

Br J Gen Pract

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Section: Comparison With Existing Literaturecontrasting

confidence: 54%

Section: Comparison With Existing Literaturecontrasting

confidence: 35%

Section: Re-evaluationmentioning

confidence: 99%

See 1 more Smart Citation

Revised guidelines for cardiovascular risk management — time to stop medication? A practice-based intervention study

Duijn¹,

Belo²,

Blom³

et al. 2011

Br J Gen Pract

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“…Unfortunately, it is unclear whether such an approach is safe. Withdrawal of antihypertensives in older persons (not specifically in the context of frailty or polypharmacy) generally has been associated with a return of hypertension without an increase in the incidence of cardiovascular disease, [89][90][91][92][93] but these studies used liberal rules for reinitiating antihypertensives and were thus underpowered. Withdrawal of diuretics has been shown to be associated with an increased risk of developing heart failure, especially in the first 4 weeks after withdrawal, 92 and withdrawal of diuretics should therefore be accompanied by strict monitoring.…”

Section: Antihypertensive Drug Treatment In the Oldest Oldmentioning

confidence: 99%

Treatment of Hypertension in the Oldest Old

et al. 2014

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A n 88-year-old woman with chronic hypertension was seen in the internal/geriatric medicine outpatient clinic. She had been treated for high blood pressure (BP) for ≈20 years with a low-dose thiazide, to which an angiotensin-converting enzyme-inhibitor had been added 5 years ago. In addition, after a possible transient ischemic attack 10 years ago, aspirin, omeprazole, and simvastatin had been added. She is known with mild cognitive impairment, which is stable with a mini-mental state examination score of 25, and a mild depression for which fluoxetine has been prescribed. In addition, she experienced 2 falls in the past 2 years; calcium/vitamin D and alendronate were started for the management of osteoporosis. On physical examination, she appears vital with a normal fluent gait and no signs of hemiparesis. Her BP is 165/75 mm Hg in the sitting position. Immediately after standing up from her chair, she feels dizzy for ≈10 seconds, but after 1 and 3 minutes, no orthostatic hypotension is found. Estimated glomerular filtration rate is 50 mL/min per 1.73 m 2 . Should antihypertensive treatment be intensified, left unaltered, or reduced?The oldest old, that is, persons aged ≥80 years, will be the fastest growing segment of the population for the next 40 years. By 2050, more than one quarter of all men and women aged ≥65 years in the Western world will be in the oldest old group. 1Despite longer life expectancy, the prevalence of various chronic diseases and functional impairment increases with age. As a result, populations of older individuals are often highly heterogeneous and individuals with same chronological age vary widely in health and functional ability. In other words, there is substantial heterogeneity in their biological age, and those at the higher end of biological age are often referred to as vulnerable or frail.BP rises with age, and ≈80% of people in Western societies aged ≥80 years have hypertension.2 Their hypertension is commonly characterized by elevated systolic BP, with often normal or even low diastolic BP. The widened pulse pressure (PP) is a reflection of increased arterial stiffness. Despite the large body of evidence in middle-aged populations, the predictive value of high BP in this rapidly growing older population is still debated, as is the question of whether hypertension should be treated, and if so, how intensively. Importantly, the current paradigm of lower is better may not apply to (untreated or treated) BP in the oldest old.In this concise narrative review, we summarize evidence from observational studies and randomized clinical trials. We conclude that biological age/frailty is becoming an important criterion for treatment decisions. Finally, we address what we think are the most pressing research questions for the coming years. Pathophysiology of BP Regulation in the Oldest OldAlthough hypertension in the oldest old may reflect a longstanding condition, often it manifests itself as a de novo abnormality. Data from the Framingham Heart Study indicate that the majority of patient...

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“…Thirdly, we did not use either beta blockers or spironolactone; thus, the results may not apply to patients treated with these drugs. Finally, the follow-up period was short although it has been demonstrated that reinstitution of diuretics generally occurs in the early weeks after discontinuation [13]. In addition, it has to be emphasized that our results are probably not applicable to more severe heart failure patients, those that are receiving more elevated doses of loop diuretics or those with advanced heart failure (New York Heart Association classes III or IV).…”

Section: Study Limitationsmentioning

confidence: 86%

Clinical and neurohumoral consequences of diuretic withdrawal in patients with chronic, stabilized heart failure and systolic dysfunction

Galve

Mallol

Catalan

et al. 2005

European J of Heart Fail

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Background: Loop diuretics are beneficial in heart failure in the short term because they eliminate fluid retention, but in the long-term, they could adversely influence prognosis due to activation of neurohumoral mechanisms. Aims: To explore the changes induced by diuretic withdrawal in chronic nonadvanced heart failure. Methods: Diuretics were withdrawn in 26 stabilized heart failure patients with systolic dysfunction (ejection fraction [EF]b45%). Clinical status was evaluated by physical exam, exercise capacity (corridor test) and New York Heart Association (NYHA) class. Biochemical and neurohumoral determinations were performed at baseline and at 3 months. Results: At 3 months, 17 out of 26 patients (65%) were able to tolerate diuretic interruption without a deterioration in exercise capacity or New York Heart Association functional class. Renal function parameters improved (baseline urea 46.2F10.8 to 39.2F10.1 mg/dl at 3 months, p=0.014; creatinine 1.1F0.23 to 0.98F0.2 mg/dl, p=0.013). Glucose metabolism also improved (fasting glucose 151F91 to 122F14 mg/dl, p=0.035). Heart rate and systolic blood pressure did not significantly change, while diastolic blood pressure increased (from 80F10 to 87F13 mm Hg, p=0.006). Neurohumoral determinations showed a decrease in plasma renin activity (4.19F5.96 to 2.88F4.98 ng/ ml, p=0.026), with no changes in aldosterone, arginine-vasopressin, endothelin-1 and norepinephrine. In contrast, atrial natriuretic peptide significantly increased (115F87 to 168F155 pg/ml, p=0.004). Conclusion: Diuretic withdrawal in stabilized heart failure with systolic dysfunction is associated with an improvement in renal function parameters, glucose metabolism and some neurohumoral parameters, such as plasma renin activity; however, atrial natriuretic peptide levels increased.

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Withdrawal of long term diuretic medication in elderly patients: a double blind randomised trial

Abstract: Objectives: About 20% of elderly people use long term diuretic medication, but there is doubt whether prolonged diuretic medication on such a large scale is necessary. We performed a study to assess what proportion may successfully be withdrawn from diuretic therapy.

Cited by 103 publications

References 15 publications

Revised guidelines for cardiovascular risk management — time to stop medication? A practice-based intervention study

Revised guidelines for cardiovascular risk management — time to stop medication? A practice-based intervention study

Treatment of Hypertension in the Oldest Old

Clinical and neurohumoral consequences of diuretic withdrawal in patients with chronic, stabilized heart failure and systolic dysfunction

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