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Withdrawing Diuretic Drugs Prescribed for Ankle Oedema

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Withdrawing Diuretic Drugs Prescribed for Ankle Oedema Diuretic drug cessation in general practice : withdrawing diuretic drugs prescribed for ankle oedema Citation for published version (APA): de Jonge, J-W. (1993). Diuretic drug cessation in general practice : withdrawing diuretic drugs prescribed for ankle oedema. Rijksuniversiteit Limburg. https://doi.org/10.26481/dis.19931201jj Document status and date: Published: 01/01/1993 DOI: 10.26481/dis.19931201jj Document Version: Publisher's PDF, also known as Version of record Please check the document version of this publication: • A submitted manuscript is the version of the article upon submission and before peer-review. There can be important differences between the submitted version and the official published version of record. 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Link to publication General rights Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights. • Users may download and print one copy of any publication from the public portal for the purpose of private study or research. • You may not further distribute the material or use it for any profit-making activity or commercial gain • You may freely distribute the URL identifying the publication in the public portal. If the publication is distributed under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license above, please follow below link for the End User Agreement: www.umlib.nl/taverne-license Take down policy If you believe that this document breaches copyright please contact us at: [email protected] providing details and we will investigate your claim. Download date: 04 Oct. 2021 DIURETIC DRUG CESSATION IN GENERAL PRACTICE t4! De tot standkoming van dit proefschrift werd mede mogelijk gemaakt door een financiele bijdrage van: de firma E. Merck Nederland B.V. te Amsterdam; ORHA Verzekeringen te Amhem; de firma ZYMA Nederland B.V. te Mijdrecht. DIURETIC DRUG CESSATION IN GENERAL PRACTICE WITHDRAWING DIURETIC DRUGS PRESCRIBED FOR ANKLE OEDEMA PROEFSCHRIFT •^ » _ ter verkrijging van de graad van doctor aan de Rijksuniversiteit Limburg tc Maastricht, op het gezag van de Rector Magnificus, Prof. Dr. H. Philipsen, volgens het besluit van het College van Dekanen, in het openbaar te verdedigen op woensdag, 1 december 1993 om 16.00 uur door geboren te Warder Promowrei: Prof. Dr. J.A. Knottnerus Prof. Dr. H.A.J. Struijker Boudier ^ ^O OTRWU«I OHWAJ*CHTIW Prof. Dr. J. Urquhart (voorzitter) Dr. A.P.M. Gorgels Prof. Dr. F.W.J. Gribnau (Katholieke Universiteit Nijmegen) Dr. K.M.L. Leunissen Prof. Dr. R.A. de Melker (Universiteit Utrecht) ....Bur /ne doc/on were Jwni/y wuer //vn /nan rney are now, and new and exercise, warwa/ion and noum/imen/, society and so/i/ude, f/wf ne jnow/d fie in fted a// day and nde ./brry m//« oenwf en /uncn and dinner, /oge/ner w/Vn /ne /v« and />n/an/j, d/vrnj/ied, ar /ne/ancy /ooil; //iem, w/rn paueu 0/ newr'j 5/oooer on min;, and draugntt o/peacocJt'5 ga// on ^oin^ /o fted, /ney /e/t /o Vfrg/nia Woo//in "Or/ando" < •"* Aan Esther Aan mijn ouders 1 Introduction i»eu»»*K» 1.1 1.2 1.3 2 General backgrounds *'£' -^ » ''"-5 * £ Si* 2.1 /fimN/ucr/o/i :<W#Ba»4»i*w*»aLj;--.*.« u 2.2 Dru; us? in r/i« ?/Jtrfy ****• 11 2.3 ///jwry o/J/i/rpnc t/rw^j 12 2.4 Afec/iflnumi <^*<icr/ons o/<//ur«/cj 14 2.5 /n</ica//0;u./&r J/uw/c Uf? 16 2.6 ^dvrn? e/fec« o/J/urfr/'c Jru^j 18 2.7 D/u;w/c-i>K/uce</ opJe/na 23 2.8 D/urff/cj a/u/ anyt/f ne^ma 24 3 Diuretic drug withdrawal trials, a review 32 3.1 iifarnic/ 33 3.2 /n/ra/wcY/on 34 3.3 A/«^0<i!i 34 3.4 Kwu/tt 37 3.5 /?«U/K o/mw/iot/o/o^/ca/ «wo/uo/(on 0///1* w/r/u/rawu/ j/««//« 43 3.6 Ducuu/o/t 44 4 Treatment of elderly patients with ankle oedema in general practice When and how often are diuretics used? 49 4.1 £um/na/y 51 4.2 /fl/roJua/o/i 31 4.3 A/e/fo*/ 53 4.4 /tou/tt 34 i 4.5 D/JCUM/O/J awi::'hi?"ii ^6 5 Methodological issues of withdrawal trials .-<<n\ ,V»*T\I;^ ' ^0 5.1 Wlfrta/ofof/co/ /JJ«« m wrVfo/rawo/ rriofa TJ>A\J imi >w"<\t t.F ^ 5.2 77K otyea/ve 61 5.3 77K /en^f/t O/^Z/J? yb//ow-i/p p^not/ ?i>4i>^njt^l9ftd ISTJO^" ^* 5.4 /»fl//en/ w/«cr/on cri/erio 62 5.6 £tc/w5/on criteria ACMM&i!y(Vi<A ' ^ 5.7 t/j* o/p/ocefto * 64 5.8 Conc/uj/onj 64 6 Research methods 67 6.1.1 /n//TH/wc«0/i 69 6.2.1 77K prewj/ence sn«/y. 69 6.2.2 /Viate on«, /</cn///^/ng po//cn« /n i'ewera/ procMce aged 65 or oWer 70 6.2.3 PAaie n«o, //ie pa/;em mo// fue^No/inai/v 71 6.3.1 Derign o/riie rria/ 72 6.3.2 Se/«crio« cn«nfl/brpflm'c/pfl/j« 73 6.3.3 Otoervario/u 75 6.3.4 Perfomi/flg o/f/ie </e/7n/r/ve w/ec//o/i o/rte pfl«>/i/5 77 6.3.5 Procedwne Jwnng m'o/ 78 6.3.6 A/oni/ori/ig 81 6.3.7 Cn/tfn'flybr cong««w/»eorr_/&//«« 82 6.3.8 Vo/umerry 84 6.4.1 Aton-«p<ri/nert/fl/^)//ow-Mp o/t«r /Ae ma/ 85 6.5.1 fta/uNc; 86 7 Results of the prevalence study 7.1 " ' 91 7.2 5.I.Q 91 ; 7.3 I 7.4 /?MU/« o/jfawid p/iarc o/ffo jffec«on: po//>n/j ovo/Vo/)/? yb * cl /nvesn'ga/fon, am/ p<3//>n/5 w/io nvnr no/ 5f« a ^uesno/vuu'rv, <//</ c?? nei/wnJ or » 7.5 J 7.6 and /w//>n/ won/* 98 7.7 /?«u/« o/r/je ific/us/o/i procedure 99 7.8 0verv/ew o/reju/tt o/"ie/e<7/on mwnoa" 101 7.9 Comparison and d/jotfj/on regard/ng j«r <inj d a«r i//5/rito//on o/ ma/ popu/arion and a// /ja//>n/i w/ea«/ on a^f and d/ur^i'c uie 106 7.10 D/5CMS5/O/I 108 8 Results of the trial 113 8.1 /n/rodwa/on 115 8.2 Aw/e/w />arr/c/00»ng in //;<» /r/a/ 115 8.3 Pa//ews >v/i0 r«/arred d/'urc/zc //?era/7>' during fne m'a/ 119 8.4 Comp/a/n/j o//K»n>n« dur/n^ rn? mo/ 121 8.5 Comp//ance /o zne in/envn/zo/t 124 8.6 Cowrje o/oedema /ndex a//er w/7ndravwng J/urfr/c drugj 125 8.7 Degree o/oedema during rne/o/Vow-u/7 period 131 8.8 Wf/gn/, peaA/7ow and Wood orejjure during/o//o*v-«/j 133 8.9 /m7wence o/" »v/7ndraw/ng d/ii/wcs o/i r/ec/ro/y/ej< , nae/na/ocri/, creo/Z/i/ne and urea 134 8.10 2uej/;on/)fl/>« aZww <7Ufl//ry o////e a/id/unc/Zona/ JW/UJ 13S 8.11 /"oii-ejtoeri/nen/a/ /b//ovv^i/o 136 8.12 9 General discussion 9.1.1 151 9.1.2 151 9.1.3 o/i 152 9.1.4 j/w/y 153 9.1.5 77K vW//u/raHu/ 153 9.2 154 9.2.1 77i* //>ro/wr? rvwVw 154 9.2.2 154 9.2.3 155 9.2.4 /no/ 155 9.3 158 9.4 Affcwn/n«K/arionj /or c/in/co/ practice 159 10 Summary 163 170 Appendix 177 Curricw/u/n 179 180 lapter 1 1.1 The general practitioner (GP) can have an important role in overseeing long-term drug use. In numerous situations the GP must decide whether to stop or to continue drugs that are being used chronically. Of course unnecessary drug use should be prevented. One of the ways to achieve this is to withdraw drugs whenever they are not useful (any more) in a given situation. Unfortunately there has as yet been little investigation of the effects of withdrawal of most therapies. This is in sharp contrast to the vast literature on the effects of starting therapies. Also the methodological aspects of studying the effects of drug withdrawal are undeveloped as compared with the methodology of trials on introducing new drugs. Therefore little is known about effects of stopping therapies in many circumstances. This might mean that withdrawal of drugs does not take place in situations where it would be appropriate.
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