Congestive heart failure diuretics

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Chronic Pharmacotherapy in HFrEF Diuretics ACE Inhibitors Angiotensin receptor blockers Aldosterone Antagonists Beta Blockers Ca Channel Blockers Nitrates Hydralazine Positive Inotropics Anticoagulants Angiotensin Receptor-Neprilysin Inhibitor Antiarrhythmic Drugs Nutritional Supplements Hormonal Therapies Drugs to Avoid Drug Interactions Treatment of underlying causes Associated conditions
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Specific Groups: Special Populations Patients who have concomitant disorders Obstructive Sleep Apnea in the Patient with CHF NSTEMI with Heart Failure and Cardiogenic Shock
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

• Provide symptomatic relief
• Slows the progression of ventricular remodeling by reducing ventricular filling pressure and wall stress
• No survival benefit and may cause azotemia, hypokalemia, metabolic alkalosis and elevation of neurohormones.
• 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.
• Fluid retention usually responds best to furosemide (Lasix) and at doses of 10 to 20 mg per day. The patient should be told to return to their physician in the next three to seven days for further assessment including assessment of their potassium concentration. Weight loss should not exceed 1 to 2 pounds/day.
• Higher lasix doses are associated with higher mortality, likely as a surrogate of disease severity rather than part of a causal pathway.
• If there is no response to the initial dose then it can be increased by at least 50%. The maintenance dose of the diuretics lower than that required to initiate diuresis.
• 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.
• 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.
• The role of potassium sparing diuretics such as spironolactone (Aldactone), amiloride, or triamterene remains the subject of controversy. Spironolactone is currently recommended as third line therapy for congestive heart failure.
• 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.

Loop Diuretics

• Agents in this class include Furosemide or lasix, bumetanide, ethacrynic acid and torsemide.
• Inhibit the Na+/K+/Cl- transporter.
• Furosemide IV reduces preload
• Relax pre-contracted pulmonary venules and thereby reduce the symptoms of pulmonary edema

Thiazide Diuretics

• Inhibit the Na+/Cl- co transporter in the distal convoluted tube.
• Recommended for management of mild chronic heart failure.

Potassium Sparing Diuretics

• Spironolactone, amiloride and triamterene.
• Inhibit principal cells in the distal convoluted tubule and cortical collecting duct.
• Inhibits Na reabsorbtion and Potassium secretion.
• Their significant side effect is hyperkalemia.

References

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