BMJ 1997;315:464-468 (23 August)

General practice

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

Edmond Walma, general practitioner,a Colette van Dooren, general practitioner,a Ad Prins, professor of general practice,a Emiel van der Does, emeritus professor of general practice,a Arno Hoes, associate professor of clinical epidemiology b

a Department of General Practice, Erasmus University Medical School, PO Box 1738, 3000 DR Rotterdam, Netherlands, b Department of Epidemiology and Biostatistics, Erasmus University Medical School, Rotterdam

Correspondence and reprints requests to: Dr Walma walma@hag.fgg.eur.nl

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 We performed a study to assess what proportion may successfully be withdrawn from diuretic therapy.
Design: Double blind randomised controlled trial with six month follow up.
Setting: General practice.
Subjects: 202 patients taking long term diuretics without manifest heart failure or hypertension.
Interventions: Patients were allocated to either placebo (withdrawal group, n=102) or continuation of diuretic treatment (control group, n=100).
Main outcome measure: Occurrence of clinical conditions requiring diuretic therapy based on fixed criteria.
Results: During follow up diuretic therapy was required in 50 patients in the withdrawal group and 13 in the control group (risk difference 36%; 95% confidence interval 22% to 50%). Heart failure was the most frequent cause of prescribing diuretic therapy (n=25). Cessation of diuretic therapy caused a mean increase in systolic blood pressure of 13.5 (9.2 to 17.8) mm Hg and in diastolic pressure of 4.6 (1.9 to 7.3) mm Hg.
Conclusion: Withdrawal of long term diuretic treatment in elderly patients leads to symptoms of heart failure or increase in blood pressure to hypertensive values in most cases. Any attempt to withdraw diuretic therapy requires careful monitoring conditions, notably during the initial four weeks.

Key messages

  • Many elderly people receive long term diuretic therapy, 45% for hypertension, 40% for heart failure, and 15 % for non-cardiac ankle oedema

  • After withdrawal of diuretics in a preselected group of elderly patients (with no manifest heart failure and satisfactorily regulated blood pressure) about half needed to restart diuretics during the next six months, usually because of heart failure

  • Average blood pressures rose considerably, by 13.5/4.6 mm Hg

  • Withdrawal of diuretic therapy does more harm than good in most patients, notably in those with heart failure

  • Rigid monitoring is needed in any attempt to withdraw diuretic therapy


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Rebound sodium and water retention occurs when diuretic treatment is stopped
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