Guidelines and tools to assess appropriateness of diuretic prescribing and aid deprescribing: a systematic review.

Abstract

Diuretics are widely used as first-line therapy for heart failure and hypertension in older adults, but long-term continuation without a clear indication can increase adverse drug events such as electrolyte disturbances, renal dysfunction, hypotension, syncope, falls, and reduced quality of life-especially in people with multimorbidity, frailty, and polypharmacy. In this systematic review of international clinical practice guidelines and expert tools published up to August, 2025, we identified 41 resources (14 guidelines, 27 tools) and synthesised 184 unique recommendations on inappropriate chronic diuretic use and deprescribing. We searched Ovid MEDLINE and Embase using predefined concepts for heart failure, hypertension, clinical practice guidelines, and deprescribing. We included English-language guidelines and deprescribing tools for adults published after October, 2013, that addressed inappropriate chronic diuretic use or deprescribing. Deprescribing guidance was comparatively sparse and most often framed as prompts to consider stopping rather than practical how-to pathways. Only 16 recommendations offered actionable support (eg, stepwise tapering or discontinuation, monitoring and safety-netting, or usable algorithms or flowcharts). Consolidated, implementation-ready deprescribing guidance is urgently needed to support safer long-term diuretic management and shared decision making.