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How to prescribe loop diuretics in oedema

BMJ 2019; 364 doi: (Published 21 February 2019) Cite this as: BMJ 2019;364:l359

Rapid Response:

Re: How to prescribe loop diuretics in oedema

Dear Drs Wong and Mohee,

We applaud your efforts to answer an important question in the management of heart failure and eagerly await the results of the randomized controlled trial you reference.


Dear Dr. Bhandari,

We agree completely that other factors play a critical role in managing oedema (from any cause), including sodium restriction, fluid restriction, compression garments, exercise, and management of factors unrelated to heart failure, such as renal failure, hepatic failure, or drug reactions. Earlier versions of this article included review of these concepts, but space limitations and our efforts to focus only on loop diuretics led to their removal.


Dear Dr. Selley,

We agree that a complete workup to determine the cause of oedema is foundational in treating these patients. Our focus was on management rather than diagnosis, however. The mention of heart failure is intended to acknowledge the preponderance of this diagnosis in the oedema population, and is not meant to suggest that the recommendations only apply to that condition. As we indicated, loop diuretics will behave in essentially the same way regardless of most other factors.


Dear Dr. Jenkinson,

We agree that cost considerations are important in selecting the most appropriate drug for treating a given condition. It is a clinical decision to determine whether the advantages of one drug over another outweigh the cost disadvantages. We had looked at cost in our analysis, although the data we had available were US results (Buggey et al, reference #20 in the article). We apologize for not adding UK costs in our analysis. We feel the advantages of torsemide likely outweigh the cost concerns, although as we have noted, this preference is based on incomplete data. More definitive research would be extremely helpful in this domain.

Competing interests: No competing interests

08 March 2019
Steven D Anisman
Bennington, VT, USA