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Diuretics are commonly prescribed for symptom relief in patients with heart failure. However, while the continued long-term use of these agents may not be required in many individuals with stable disease being treated on an outpatient basis, guidance on diuretic withdrawal from clinical trials or clinical practice guidelines is lacking.
The results of a randomised trial investigating just this approach was reported in a latebreaking trial (LBT26) yesterday by Doctor Andreia Biolo (Hospital de Clinicas de Porto Alegre, Brazil).
Together with the principal investigator, Doctor Luis Eduardo Rohde, from the same institute, Dr. Biolo expands on the decision to conduct the trial. There is some suggestion that long-term diuretic usage may be associated with a poor prognosis. In addition, as the medical management of heart failure becomes increasingly complex, the opportunity to simplify treatment by removing an unnecessary agent is appealing.
The ReBIC-1 trial is the first multicentre (involving 11 centres across Brazil), double-blind, randomised trial to address the question of diuretic withdrawal in stable, apparently euvolemic outpatients with chronic heart failure (New York Heart Association class I–II) and mild symptoms. Patients receiving daily furosemide were randomised to withdrawal (n=95) or continuation (n=93) of their diuretic and followed up for 90 days.
The results from the ReBIC-1 trial provide the first real confirmation that it is safe to withdraw diuretics in stable patients with class I–II chronic heart failure without a significant impact on patients’ perceptions of dyspnoea or an undue requirement for diuretic reinstatement.
There was no difference between furosemide withdrawal and continuation in the co-primary endpoints of patients’ global assessment of dyspnoea—based on a visual analogue score (p=0.64)—or in the proportion of patients free from furosemide reuse during follow-up (74.3% vs 83.9%; p=0.16). The lack of a difference between withdrawal and continuation was maintained in a subgroup analysis based on median levels of baseline NT-proBNP levels. In addition, diuretic withdrawal did not lead to an increase in hospital admissions.
Although the follow-up was only 90 days, Dr. Biolo stresses that any adverse effects of diuretic withdrawal, in terms of worsening of symptoms or decompensation, would be expected to be observed within the first few weeks. “If a patient is able to tolerate diuretic withdrawal for 90 days, it is likely that they do not require this treatment.
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