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==Diuretics==
==Diuretics==
===Background===
===[[Diuretics]]===
====Benefits of Diuretics====
*[[Loop diuretics]] is recommended to reduce the signs and/or symptoms of [[congestion]] in [[patients]] with [[ HFrEF]].<ref name="pmid30600580">{{cite journal |vauthors=Mullens W, Damman K, Harjola VP, Mebazaa A, Brunner-La Rocca HP, Martens P, Testani JM, Tang WHW, Orso F, Rossignol P, Metra M, Filippatos G, Seferovic PM, Ruschitzka F, Coats AJ |title=The use of diuretics in heart failure with congestion - a position statement from the Heart Failure Association of the European Society of Cardiology |journal=Eur J Heart Fail |volume=21 |issue=2 |pages=137–155 |date=February 2019 |pmid=30600580 |doi=10.1002/ejhf.1369 |url=}}</ref>
*Reduction of the intravascular volume
* The effects of [[diuretics]] on [[morbidity]] and [[mortality]] have not been studied in [[RCTs]].
*Reduction of the preload and relaxation of the pulmonary venules
*[[Loop diuretics]] and [[thiazide diuretics]] appear to reduce the risk of death and worsening [[HF]] compared with a placebo.
*Reduction of the wall stress
*[[Diuretics]] can improve [[exercise capacity]].<ref name="pmid11853901">{{cite journal |vauthors=Faris R, Flather M, Purcell H, Henein M, Poole-Wilson P, Coats A |title=Current evidence supporting the role of diuretics in heart failure: a meta analysis of randomised controlled trials |journal=Int J Cardiol |volume=82 |issue=2 |pages=149–58 |date=February 2002 |pmid=11853901 |doi=10.1016/s0167-5273(01)00600-3 |url=}}</ref>
*Improvement of the left ventricular remodeling
* [[Loop diuretics]] and [[thiazides]] act synergistically and may be used to treat [[diuretic resistance]].
*Improvement of symptoms but not survival
* [[ARNI]], [[MRAs]], and [[SGLT2 inhibitors]] may also possess [[diuretic]] properties.
**In fact higher doses of lasix are associated with higher mortality, likely as a results of higher doses being a marker of more severe disease.
* Maintaining the euvolemia state is the aim of [[diuretic therapy]] with the lowest doses.<ref name="pmid31424503">{{cite journal |vauthors=Rohde LE, Rover MM, Figueiredo Neto JA, Danzmann LC, Bertoldi EG, Simões MV, Silvestre OM, Ribeiro ALP, Moura LZ, Beck-da-Silva L, Prado D, Sant'Anna RT, Bridi LH, Zimerman A, Raupp da Rosa P, Biolo A |title=Short-term diuretic withdrawal in stable outpatients with mild heart failure and no fluid retention receiving optimal therapy: a double-blind, multicentre, randomized trial |journal=Eur Heart J |volume=40 |issue=44 |pages=3605–3612 |date=November 2019 |pmid=31424503 |doi=10.1093/eurheartj/ehz554 |url=}}</ref>
* [[Patients]] should be trained to self-adjust their [[diuretic]] dose based on monitoring of symptoms/signs of [[congestion]] and daily [[weight]] measurements.


====Thiazide Diuretics====
* Inhibit the Na+/Cl- co transporter in the distal convoluted tube.
* Although [[thiazide]] [[diuretics]] are effective in mild [[heart failure]] they are usually inadequate for the treatment of severe [[heart failure]].
* [[Thiazide]] [[diuretics]] have also been associative with [[hyponatremia]].


====Loop Diuretics====
* Agents in this class include [[Furosemide]] or [[lasix]], [[bumetanide]], [[ethacrynic acid]] and [[torsemide]].
* Loop diuretics inhibit the Na+/K+/Cl- transporter.
* Fluid retention usually responds best to [[furosemide]] (Lasix)
** If there is no response to the initial  dose then it can be increased by at least 50%.
* The maintenance dose of the [[diuretics]] is lower than that required to initiate diuresis, and for lasix it is usually 10 to 20 mg per day.
* The patient should be told to return to their physician in the next three to seven days after initiation for further assessment including assessment of their [[potassium]] concentration.
* Weight loss should not exceed 1 to 2 pounds/day.
* If the patient gains more than two pounds and they are instructed to double the dose of their loop diuretic.
* Once the baseline weight has been re-established than they can resume their previous status.
* Higher lasix doses are associated with higher mortality, likely as a surrogate of disease severity rather than part of a causal pathway.
* Intermittent use of [[metolazone]] into dose of 2.5 or 5 mg can be given if the patient is refractory to [[furosemide]] Lasix. [[Metolazone]] should be given in the inpatient setting.


====Potassium Sparing Diuretics====
====Potassium Sparing Diuretics====

Revision as of 14:53, 2 March 2022
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]

Overview

Diuretics reduce circulating volume, improve symptoms and are a mainstay of therapy for congestive heart failure. While these agents improve symptoms, they have not been associated with a reduction in mortality and are associated with electrolyte imbalances.

Diuretics

Diuretics


Potassium Sparing Diuretics

  • The role of potassium sparing diuretics such as spironolactone (Aldactone), amiloride, or triamterene remains the subject of controversy.
  • Spironolactone is currently recommended only as third line therapy for congestive heart failure.
  • These agents inhibit Na reabsorbtion and Potassium secretion in the distal convoluted tubule and cortical collecting duct.
  • Their significant side effect is hyperkalemia.
  • Extreme caution is necessary when adding a potassium sparing agent to the regiment that includes ACE inhibitors particularly when diabetes or renal disease is present because the patient can become hyperkalemic.

Complications

2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure

Diuretics in Patients Presenting With Heart Failure (DO NOT EDIT) [4][5]

Class I

1. Diuretics should be used for relief of symptoms due to volume overload in patients with HFpEF. (Class I, Level of Evidence: B)

External Links

References

  1. ↑ Mullens W, Damman K, Harjola VP, Mebazaa A, Brunner-La Rocca HP, Martens P, Testani JM, Tang W, Orso F, Rossignol P, Metra M, Filippatos G, Seferovic PM, Ruschitzka F, Coats AJ (February 2019). "The use of diuretics in heart failure with congestion - a position statement from the Heart Failure Association of the European Society of Cardiology". Eur J Heart Fail. 21 (2): 137–155. doi:10.1002/ejhf.1369. PMID 30600580. Vancouver style error: initials (help)
  2. ↑ Faris R, Flather M, Purcell H, Henein M, Poole-Wilson P, Coats A (February 2002). "Current evidence supporting the role of diuretics in heart failure: a meta analysis of randomised controlled trials". Int J Cardiol. 82 (2): 149–58. doi:10.1016/s0167-5273(01)00600-3. PMID 11853901.
  3. ↑ Rohde LE, Rover MM, Figueiredo Neto JA, Danzmann LC, Bertoldi EG, Simões MV, Silvestre OM, Ribeiro A, Moura LZ, Beck-da-Silva L, Prado D, Sant'Anna RT, Bridi LH, Zimerman A, Raupp da Rosa P, Biolo A (November 2019). "Short-term diuretic withdrawal in stable outpatients with mild heart failure and no fluid retention receiving optimal therapy: a double-blind, multicentre, randomized trial". Eur Heart J. 40 (44): 3605–3612. doi:10.1093/eurheartj/ehz554. PMID 31424503. Vancouver style error: initials (help)
  4. ↑ 4.0 4.1 Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 20; 112(12): e154-235. Epub 2005 Sep 13. PMID 16160202
  5. ↑ 5.0 5.1 Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 119 (14):1977-2016. DOI:10.1161/CIRCULATIONAHA.109.192064 PMID: 19324967

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