Diuretic therapy provides the mainstay of symptomatic management of heart failure. However, evidence is lacking demonstrating morbidity and mortality benefits. Generally monotherapy with loop diuretics (known as high ceiling agents as response increases with increasing dose) or thiazide diuretics (known as low ceiling agents as optimum response is reached at low dose) is preferred. Patients with refractory oedema may require combination therapy, although this increases the risk of provoking biochemical disturbances. Generally loop diuretics are first line therapy when treating decompensation. The loop of choice would be furosemide, with bumetanide reserved for those patients unresponsive to furosemide.

People who have HFrEF should usually be offered a low to medium dose of loop diuretics (for example, less than 80 mg furosemide per day). People whose heart failure does not respond to this treatment will need further specialist advice

NB. 1mg of bumetanide is equivalent to a 40mg dose of furosemide.

It may be necessary to continue diuretic therapy even if patient develops an AKI. See “problem solving” for further advice.

This advice applies to monitoring of pharmacotherapy in clinically stable patients; it does NOT apply to patients with intercurrent acute illness.

Loop diuretics should routinely be used for the relief of congestive symptoms and fluid retention in patients with heart failure, and titrated (up and down) according to need following the initiation of subsequent heart failure treatments. Some patients will require diuretics as maintenance therapy.

Check pre-treatment blood chemistry. (e.g., serum creatinine, urea, potassium, sodium and eGFR) and blood pressure.

Use the immediate pre-treatment serum creatinine concentration as the baseline.

• Start with a low dosage of oral furosemide and increase slowly until clinical improvement of signs and symptoms of congestion.

• Dose must be adjusted, particularly after restoration of dry weight, to avoid the risk of renal dysfunction and dehydration.

• Aim to achieve dry weight with lowest achievable dose

The following checks should be carried out before increasing/decreasing loop diuretics: Patient weight, fluid status, heart rate, BP, JVP and blood chemistry (e.g., serum creatinine, urea, potassium, sodium and eGFR)

Increasing dose

If the patient presents with signs of worsening heart failure with either:

• An increase of weight of 1.5-2kg in 2-3 days.

• Increasing peripheral or sacral oedema

Consider the following:

• Does the patient have features indicating severe decompensated heart failure that may warrant hospital admission?

• Is the patient taking ≥80mg of furosemide twice daily, or the equivalent dose of bumetanide?

• Is the peripheral oedema above knee level?

If so advice should be sought from the heart failure specialist team or hospital physician before increasing the dose

If not:

• Where possible ascertain & treat the cause of fluid retention e.g., noncompliance with medicines, infection of any cause, atrial fibrillation and fluid or salt excess.

• Patients should be advised to limit their salt and fluid intake (1.5 -2litres per day). Ask patient to record daily weights.

• The patient’s diuretic dose should be increased or initiated initially for 3 days. Furosemide should generally be increased in 40mg increments, bumetanide in 1mg increments (see below)

• The patient should be reviewed again after 3 days. An adequate response to treatment would be improved symptoms and weight reduction of 0.5 kg/day. The dose increment should be maintained, and advice sought if the dry weight is not regained after 3 days of increased diuretic therapy.

A thiazide diuretic (e.g., bendroflumethazide) can be used in combination with a loop diuretic, in cases of severe fluid overload. This will result in a powerful diuresis and should be initiated only on advice from a cardiologist or the heart failure team.

Dose Titration - Decreasing dose

• This should only be undertaken cautiously. The dose should only be reduced from the usual maintenance only if there are signs of volume depletion and hypoperfusion, i.e., evidence of significant weight loss from dry weight (> 1 kg) rising blood urea (> 5 mmol/L or > 25 per cent) and/or symptoms of dizziness (e.g., postural hypotension) or feeling “dried out”.

• The dose of diuretic should not be reduced if there is peripheral oedema or if the JVP is elevated. If the patient has a rising blood urea, falling weight and/or symptoms of dizziness/dehydration but peripheral oedema consider seeking advice from a cardiologist.

• Dose reduction should be carried out by 40mg furosemide or 1mg bumetanide increments that are the reverse of the uptitration guidelines outlined above.

• The patient should be contacted 48 hours later to assess his/her response to the dose reduction.

Symptomatic hypotension (<100mmHg associated with dizziness, fainting and confusion)

Discuss with cardiologist regarding fluid and electrolyte replacement with careful monitoring of serum electrolytes:

• Check blood chemistry

• Encourage fluid intake

• Withhold one to three diuretic doses and lower doses by one step (as per table above).

• Counsel patients to avoid abrupt postural changes

• Reassess BP and hypotensive symptoms in 3 days

• If patient remains symptomatic, review vasodilators and if taking ramipril once a day, consider splitting dose to twice a day. Reassess BP and hypotensive symptoms in 3 days if symptoms persist consult specialist.

Electrolyte disturbances

May be manifested by weakness, dizziness, mental confusion, anorexia, lethargy, vomiting, and cramps.

Hypokalaemia

The serum potassium level may overestimate total body potassium stores.

• Consider increasing ACEI/ARB if possible or replace with Sando K usual dose 2 tds for 3 days.

• Consider addition of spironolactone if clinically indicated.

Hypomagnesaemia

Discuss with Consultant Cardiologist.

Hyponatraemia

• Fluid restriction

• Reduce or stop diuretics if possible

• Seek advice if serum sodium falls below 130mmol/L (this is a poor prognostic indicator)

Insufficient response or diuretic resistance

• Check compliance and fluid intake

• Increase dose of diuretic as detailed above

• Consider switching from furosemide to bumetanide

• Administer loop diuretic twice daily or on an empty stomach

• Discuss with the heart failure team or a cardiologist for other options for management

Hypovolaemia/dehydration

• Assess volume status

• Consider diuretic dose reduction as documented above

Hyperuricaemia/gout

• For acute gout attacks, physician to treat with colchicine and avoid NSAIDS.

• For frequent gout attacks, consider prophylaxis with allopurinol.

Increased fasting blood sugar

Review for new diagnosis of diabetes.

Renal Failure

• Check for hypovolaemia/dehydration

• Exclude other nephrotoxic agents, e.g., NSAIDs, Trimethoprim

• Withhold aldosterone antagonist

• Consider a reduction of ACEI/ARB in line with individual drug guidelines

• Discuss with renal team or heart failure team at the hospital with regards to deteriorating renal function.

Rash/allergy to furosemide

Bumetanide can be used in patients allergic to furosemide.

Photosensitivity

Take protective measure (sunscreen, protective clothing) against exposure to UV light or sunlight.

• Time of taking the loop diuretic is not fixed, however it is better to avoid taking after 4pm as this can lead to nocturia

• Report dizziness/light-headedness as this may be indicative of over treatment

• Encourage patient to self-weigh daily (after waking and voiding but before breakfast and dressing) and an action plan if sudden weight gain.

• Report sudden or sustained weight increase or decrease (more than 1.5-2kg kg over 2-3 days) to a specialist nurse or GP

• Report any symptoms of fluid overload, i.e., increased breathlessness, frothy sputum, peripheral oedema to a specialist nurse or GP

• Diarrhoea, vomiting, poor fluid intake exacerbate dehydration. Contact GP if persists for > 2-3 days. Special caution needed in prolonged periods of hot weather.

• Warn of increased risk of gout occurring.

Chronic Heart Failure in Adults: Diagnosis and Management. NICE clinical Guideline CG106. Issued September 2018. Available at: www.nice.org.uk/guidance/ng106 (Accessed 08/03/22)

Theresa A McDonagh et al, 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC, European Heart Journal, Volume 42, Issue 36, 21 September 2021, Pages 3599–3726, Available at:  https://doi.org/10.1093/eurheartj/ehab368 (Accessed 07.03.22). Correction published 21 December 2021, https://doi.org/10.1093/eurheartj/ehab670

Summary of product characteristics for Burinex available online at https://www.medicines.org.uk/emc

With thanks to the Sussex Heart Network, from whom these guidelines were adapted

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.
This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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