Walma EP, Hoes AW, Prins A, et al. Withdrawing long-term diuretic therapy in the elderly: a study in general practice in The Netherlands. Family Medicine 1993;25(10):661-64
PubMed link: https://www.ncbi.nlm.nih.gov/pubmed/8288071
| Methods | Study design: Before-and-after study
Number of groups: One group |
| Participants | Number of participants: 15 enrolled
Age: 78 years (range 67 to 90 years) Sex: 11 female, 4 male Participants with dementia: No Inclusion criteria: · Age 65 or older · Currently· using diuretics for six months or longer · Patient at the participating general practice Exclusion criteria: · Hypertension for less than one year, even if it was treated and well controlled · Unsatisfactorily regulated hypertension (defined as more than one measurement over 165/95 mmHg) · Documented medical history of one or more episodes of acute left-sided congestive heart failure · Heart failure scores over three points based on anamnesis and physical examination, adapted from a scoring system reported by Georghiade et al · Edema caused by renal or hepatic disease, hypercalcemia, or glaucoma · Unable to adequately answer simple questions about his/her health status, according to the general practitioner Country: The Netherlands Setting: Community – one general practice of approximately 2,000 patients in Schoonhoven, a small town (population 11,000) located 20 miles east of Rotterdam in The Netherlands |
| Interventions | Medicine: Diuretics
· Indication for use were: heart failure (n=7), hypertension (n=2), heart failure plus hypertension (n=1), ankle edema (n=1), and unknown (n=4) Withdrawal schedule: · Thiazides and furosemide in daily dosages of <40 mg were stopped abruptly · Frusemide daily dosages of 40 mg were halved during one week before complete withdrawal |
| Outcomes | Successful deprescribing
Blood pressure Heart failure score Weight Ankle circumference |
| Dates | Dates: Not described
Follow-up duration: Six months |
| Funding sources | Dutch Organization for Scientific Research |
| Notes |
Risk of bias table
| Bias | Authors’ judgment | Support for judgment |
| Random sequence generation (selection bias) | High risk | Not randomized. |
| Allocation concealment (selection bias) | High risk | Open study. |
| Blinding of participants and personnel (performance bias) | 5 out of 5 | Not blinded. |
| Blinding of outcome assessment (detection bias) | 5 out of 5 | Not blinded. |
| Incomplete outcome data (attrition bias) | 1 out of 5 | No missing data. |
| Selective reporting (reporting bias) | 5 out of 5 | Outcome measures were pre-specified as Heart failure Systolic BP Diastolic Request of patientFour outcomes are reported in a single sentence with only the change and significance reported, rather than absolute values before or after deprescribing. |
| Confounding (non-randomized) | 5 out of 5 | A large number of confounders were excluded.
The study protocol was approved by an ethics committee, though as it was not published it is unclear how thorough the analysis plan was or if the authors adhered to it. However, the stated objectives are reported. |
| Other bias | Unclear risk | No conflicts of interest reported.
Insufficient detail to establish other potential sources of bias. |
| Newcastle-Ottawa scale | ||
| Selection bias | Representativeness of the exposed cohort | Selected group of users. |
| Selection of the non-exposed cohort | No description of the derivation of the non-exposed cohort.
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| Ascertainment of exposure | Ascertainment of exposure by structured interview.
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| Demonstration that outcome of interest was not present at start of study | Demonstrated that outcome of interest was not present at start of study | |
| Comparability bias | Comparability of cohorts on the basis of the design or analysis | The study controlled for withdrawal of diuretics. |
| Outcome bias | Assessment of outcome | Outcomes assessment by structured interview. |
| Was follow-up long enough for outcomes to occur
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Follow-up was not long enough for outcomes to occur. | |
| Adequacy of follow-up of cohorts | Complete follow-up – all subjects accounted for. | |
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