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 Study Finds Epidemic Overuse Of Diuretics

​A study in the Journal of the American Medical Directors Association (JAMDA) is ringing alarm bells about what the author sees as an “epidemic overuse” of diuretic drugs among the elderly.

Martin Wehling, director of Clinical Pharmacology at the Mannheim Center for Gerontopharmacology at the University of Heidelberg, says that diuretics are commonly prescribed for a range of problems from high blood pressure to kidney diseases. But they also can have nasty side effects that are particularly dangerous to the elderly. Worse, he says, most medical guides (including the United States, where Wehling derives most of his data), “invariably recommend diuretics, and, thus, most treatments are formally in line with guidelines; however, this apparent guideline adherence does not reflect the gap of evidence for the elderly.”

“Thus,” Wehling says, “evidence-based guidelines do not really exist for the elderly, and existing guidelines may be seen as a threat to them. Therefore, the individualization of treatments according to the particular needs, vulnerabilities, and comorbidities of the elderly is of paramount importance.”
Wehling, publishing his findings in the latest issue of the JAMDA, says that “inappropriate use of diuretics” should have its own name, which he calls “morbus diureticus.”

Consider, for example, the class of diuretics known as thiazides, Wehling says. Thiazides commonly are used to treat high blood pressure and edema and “are the most prescribed drugs in the United States, with more than 134 million prescriptions in 2008.” However, they’re also one of the leading worst offenders for adverse drug reactions (ADRs): “In an administrative database analysis, they were a rank 7 as culprits for ADRS in hospitalized patients,” Wehling says.

But they’re even more dangerous for the elderly, Wehling says. “Interestingly, they progress to rank 2 in the age group of 90 to 99 years, underlining their particularly toxicity,” he says.

The adverse reactions seem to land hardest on the elderly, starting chain reactions that sometimes conceal diuretics’ role in a patient’s death, Wehling says. For instance, diuretics often cause electrolyte disturbances—causing hypokalemia, when the body has its core nutrients flushed away.

Elderly patients being treated for high blood pressure with diuretics were more than seven times more likely to suffer from hypokalemia than those without diuretics, Wehling says.
It gets worse from there, he says.

“In hypertension treatment, several studies point to an increased cardiovascular mortality and rate of sudden death in hypokalemic patients,” he says. “Similar results have been reported for an excess mortality of patients with heart failure by diuretics. It is alarming that hypokalemia in hospitalized patients (mainly suffering from heart failure) who had a 10-fold excess mortality in comparison with normokalemic patients, is adequately treated and corrected in only 24 percent of cases.”

Diuretics also can cause dehydration and diabetes, each of which bring a train of problems for the elderly, Wehling says.

“Pharmacoepidemiologic studies show that this threat is real, although exact data on the burden of disease or even excess mortality owing to inappropriate use of diuretics are missing,” Wehling says.

He suggests that his proposed diagnoses be used specifically for the mis- or overuse of diuretics in the elderly. “It should be diagnosed by history-taking and physical examination to exactly determine drug history, side effects, and the need for diuretics and to search for alternatives or lower doses by matching disease diagnoses and severity,” he says. “More research is urgently needed to better describe the human use of diuretics regarding both benefits and toxicities.”

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