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.

[Image: see text]

Aging and Later Life Amsterdam Public Health Research Institute Amsterdam The Netherlands

Department of Anesthesiology Pharmacology and Therapeutics Faculty of Medicine University of British Columbia Vancouver Canada

Department of Geriatrics 1st Faculty of Medicine Charles University Prague Czech Republic

Department of Internal Medicine Geriatrics Amsterdam University Medical Center University of Amsterdam Meibergdreef 9 Amsterdam The Netherlands

Faculty of Health and Social Sciences University of South Bohemia České Budějovice Czech Republic

General Faculty Hospital Prague Czech Republic

Istanbul Medical Faculty Department of Internal Medicine Division of Geriatrics Capa Istanbul University Istanbul Turkey

Leslie Dan Faculty of Pharmacy University of Toronto Toronto Ontario Canada

Medical Library Amsterdam University Medical Center University of Amsterdam Amsterdam The Netherlands

Pharmacy Department IRCCS San Raffaele Hospital Milan Italy

Trillium Health Partners Mississauga Ontario Canada

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