Diuretic Therapy for Patients With Heart Failure

A. Diuretic Therapy for Patients With Heart Failure: JACC State-of-the-Art Review(published March 17 2020)

Important summary includes-

(i) Initial loop diuretic dosing in patients hospitalized with HF and congestion

For patients on long-term loop diuretic agents, 2.5, their outpatient dose on a mg per mg basis(DOSE trial). For example, for patients taking 40 mg of oral furosemide twice daily as an outpatient, initial IV dosing would be 100 mg of furosemide IV twice daily.

For patients not receiving long-term loop diuretics agents, 40–80 mg IV BID of furosemide or the equivalent is a reasonable empiric starting dose. Due to post-dosing Na retention, IV loop diuretic agents should usually be given at least twice daily.

(ii)Adjustment of diuretic dosing

Subsequent doses of loop diuretic agents should be guided by clinical response to initial doses. For a sufficient dose of loop diuretic agent, urine output should measurably increase within 2 h. If there is not an adequate response to initial dose, there is no need to wait until the next scheduled dose to increase dosing.

Urine Na monitoring may also be an effective strategy to guide diuretic dosing, although not yet tested in large studies

(iii) Responding to increasing serum creatinine during diuretic therapy for congestion

Although clinical context is key, increases in serum creatinine (up to a 0.5 mg/dl increase) during diuretic treatment are common and do not always necessitate stopping or decreasing loop diuretic dosing, especially if congestion is persistent.

Clinical trial data suggest that such changes are usually transient and associated with similar or even better long-term outcomes in the setting of effective decongestion.

(iv) Dealing with diuretic resistance

Identification of the resistance mechanism(s) can facilitate individualized strategies to improve diuretic response. Combination nephron blockade by adding at thiazide-like diuretic agent (most often metolazone) to loop diuretic agents often results in robust
diuresis, but there is substantial risk of electrolyte abnormalities with this approach.

Renal mechanisms for Diuretic resistance

Management of Diuretic Resistance : An Overview

(v) Adjusting chronic loop diuretic dosing during optimization of GDMT

In general, the goal of long-term dosing is use of the lowest dose that permits effective maintenance of volume status. Optimization of GDMT may allow reduction in loop diuretic dosing, and dose reduction may be required to mitigate the risk of hypotension or volume depletion (i.e., after initiation of sacubitril-valsartan).