Ba Khadija, Sow Mamadou Adama, Magne Julien, Salle Laurence, Lacroix Philippe, Chastaingt Lucie, Aboyans Victor
EpiMaCT, Inserm 1094, IRD, Limoges University Hospital, 87025 Limoges, France.
EpiMaCT, Inserm 1094, IRD, Limoges University Hospital, 87025 Limoges, France; Department of Cardiology, Dupuytren University Hospital, 87025 Limoges, France.
Arch Cardiovasc Dis. 2023 Jun-Jul;116(6-7):357-363. doi: 10.1016/j.acvd.2023.04.002. Epub 2023 Apr 28.
Recently, increased risk of amputation under sodium glucose cotransporter-2 inhibitors has been debated. Similar concerns have been raised with other "traditional" diuretics, more particularly in patients with or at risk of lower extremity arterial disease (LEAD).
To collect all available data on any potential risk of amputation associated with diuretics in patients with or at risk of LEAD. Additionally, we looked for other limb-related events in these patients.
We searched in PubMed, Embase and Scopus databases up to February 2021 for references, using peripheral or lower extremity arterial disease, diuretics and amputation keywords, excluding case reports, experimental animal studies and non-English reports.
Among the 1376 hits identified in the databases, six studies were finally included in this review, including one cross-sectional and five longitudinal studies (total of 47,612 participants). One study was limited to thiazide diuretics, one focused on loop diuretics and the remainder mixed all diuretics. All studies reported a significant association between diuretic use and amputation risk in patients with or at high risk of LEAD. Despite some limitations in several studies, the meta-analysis showed an increased risk of amputation associated with diuretics (odds ratio: 1.75, 95% confidence interval: 1.53-1.99; P<0.001). Beyond amputation, patients with or at risk of LEAD under diuretics appeared to be at increased risk of other lower limb events, mostly in the presence of other comorbidities, including diabetes.
Although the amount of data in the literature is scarce, this first systematic review and meta-analysis favours an increased risk of amputation in patients with or at risk of LEAD under diuretics. Further prospective studies must be conducted to provide a better understanding of the mechanisms. Meanwhile, the use of diuretics in these patients should be parsimonious, considering alternatives whenever possible.
最近，钠-葡萄糖协同转运蛋白2抑制剂（SGLT-2抑制剂）治疗下截肢风险增加的问题一直存在争议。其他“传统”利尿剂也引发了类似担忧，尤其是在患有下肢动脉疾病（LEAD）或有下肢动脉疾病风险的患者中。
收集所有关于利尿剂与LEAD患者或有LEAD风险患者截肢潜在风险的可用数据。此外，我们还研究了这些患者中其他与肢体相关的事件。
截至2021年2月，我们在PubMed、Embase和Scopus数据库中检索参考文献，使用外周或下肢动脉疾病、利尿剂和截肢等关键词，排除病例报告、实验动物研究和非英文报告。
在数据库中识别出的1376条记录中，本综述最终纳入了6项研究，包括1项横断面研究和5项纵向研究（共47612名参与者）。1项研究仅限于噻嗪类利尿剂，1项聚焦于袢利尿剂，其余研究则混合了所有利尿剂。所有研究均报告了利尿剂使用与LEAD患者或高危患者截肢风险之间存在显著关联。尽管几项研究存在一些局限性，但荟萃分析显示，利尿剂与截肢风险增加相关（优势比：1.75，95%置信区间：1.53-1.99；P<0.001）。除截肢外，使用利尿剂的LEAD患者或有LEAD风险的患者似乎其他下肢事件的风险也增加，主要是在存在包括糖尿病在内的其他合并症的情况下。
尽管文献中的数据量较少，但这项首次系统性综述和荟萃分析支持使用利尿剂的LEAD患者或有LEAD风险的患者截肢风险增加。必须进行进一步的前瞻性研究，以更好地理解其机制。同时，在这些患者中应谨慎使用利尿剂，尽可能考虑其他替代药物。
