EUH Morning Report: What is the ideal diuretic dosing strategy for diuretics in a patient admitted from home with acute decompensated HF and already on home diuretics?

The Bottom Line: In managing patients admitted with heart failure exacerbation, the DOSE trial confirmed that furosemide (Lasix) intermittent bolus is equivalent to continuous drip, making continuous drip management unnecessary in nearly all situations. Furthermore, symptoms were similar in high dose bolus furosemide compared to low dose bolus furosemide, with only marginal differences in creatinine change in high-dose vs. low-dose furosemide boluses. However, the high-dose bolus patients had greater daily weight loss (more than 1kg additional fluid weight lost per day) compared to low dose patients.

Clinicians may consider up to 2.5 times the patient’s home daily furosemide dose, converted to IV in their diuretic bolus dosing for admitted patients with heart failure exacerbations.

Reference: Felker GM, Lee KL, Bull DA, Redfield MM, et al. Diuretic strategies in patients with acute decompensated heart failure. NEJM. 2011 Mar 3; 364(9):797-805.

Summary:  Although loop diuretics are an essential component of therapy for acute decompensated heart failure, there have been few prospective data to guide decision-making regarding the use of these agents. In the DOSE trial, no significant differences were found in either the patients’ global assessment of symptoms or the change in the creatinine level from baseline to 72 hours when diuretic therapy was administered by means of boluses as compared with continuous infusion or with a low-dose strategy as compared to a high-dose strategy (Felker et al, 2011).

Bolus vs. continuous infusion:

  • No difference in serious adverse events (44% in each group)
  • More cases of ventricular tachycardia with boluses than with continuous infusions (7 vs. 4)
  • More cases of renal failure with continuous infusion than with bolus (11 vs. 8)
  • More cases of myocardial infarction with boluses (4 vs. 1)

*These findings are not consistent with prior, smaller studies suggesting that continuous infusion, as compared with boluses, is associated with a lesser degree of renal dysfunction and greater diuresis.

High-dose vs. low-dose strategy:

  • Fewer in the high-dose group had serious adverse event than in the low-dose group (38% vs. 50%)
  • More cases of ventricular tachycardia with low-dose strategy than with high-dose strategy (7 vs. 4)
  • More cases of renal failure with low-dose strategy (12 vs. 7)
  • More cases of myocardial infarction with low-dose strategy (4 vs. 1)

*These findings suggest that prior observations linking high-dose diuretics with poor outcomes may reflect the severity of the illness rather than a harmful effect of high doses.

It must be noted that this study used a continuous placebo infusion in the patients assigned to boluses. The authors admit that this feature of the study design may have served to increase the time the patients were supine, a position that has been shown to enhance diuresis (Felker et al, 2011, p. 803). Also, the bolus group tended to receive a higher dose of the diuretic than did the continuous-infusion group.

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