Can a patient with elevated B-type natriuretic peptide (BNP) levels, currently taking Hydrochlorothiazide (HCTZ), add Furosemide (Lasix) to their treatment regimen?

From the Guidelines

Yes, a patient with a BNP of 3,000 who is already taking hydrochlorothiazide (HCTZ) can add furosemide (Lasix), as this combination is often necessary in severe heart failure when a single agent is insufficient to manage fluid overload, as recommended by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. The high BNP indicates substantial volume overload and heart failure that requires more aggressive diuresis.

• Key points to consider when adding furosemide include:
  • Starting dose: 20-40mg once or twice daily, which can be titrated based on clinical response
  • Monitoring for electrolyte abnormalities (particularly potassium, sodium, and magnesium), renal function changes, and signs of dehydration
  • The synergistic effect of combining HCTZ and furosemide, which work at different sites in the nephron, can enhance diuresis
  • Patient education on monitoring daily weights, restricting fluid intake to 1.5-2 liters daily, following a low-sodium diet, and reporting symptoms like increased shortness of breath, swelling, or dizziness According to the 2022 guideline, loop diuretics like furosemide are the preferred diuretic agents for use in most patients with heart failure, and thiazide diuretics like HCTZ may be considered in patients with hypertension and heart failure and mild fluid retention 1.
• The treatment goal of diuretic use is to eliminate clinical evidence of fluid retention, using the lowest dose possible to maintain euvolemia, and diuretics should not be used in isolation but always combined with other guideline-directed medical therapy (GDMT) for heart failure that reduces hospitalizations and prolongs survival 1.

From the FDA Drug Label

The usual initial dose of Furosemide tablets is 20 to 80 mg given as a single dose. Adults The usual initial dose of Furosemide tablets for hypertension is 80 mg, usually divided into 40 mg twice a day. To prevent excessive drop in blood pressure, the dosage of other agents should be reduced by at least 50% when Furosemide tablets are added to the regimen

The patient can add Lasix (furosemide) to their current medication regimen, but the dosage of HCTZ should be reduced by at least 50% to prevent excessive drop in blood pressure when Lasix is added. The initial dose of Lasix can be 20 to 80 mg given as a single dose, and the dosage can be adjusted according to the patient's response 2, 2.

From the Research

Patient with Elevated BNP and HCTZ Treatment

• The patient has a BNP level of 3,000 and is already taking HCTZ, a diuretic commonly used to treat fluid retention and high blood pressure.
• The question is whether Lasix (furosemide), another diuretic, can be added to the patient's treatment regimen.

Diuretic Therapy in Heart Failure

• According to 3, natriuretic peptides, including BNP, are used to guide therapy in heart failure, but the data on their effectiveness is conflicting.
• 4 suggests that BNP exhibits roles in natriuresis and diuresis, making it a potential aid in diuresing fluid-overloaded patients, but clinical trials have not demonstrated beneficial outcomes.
• 5 found that extremely elevated BNP levels (>1694pg/mL) are associated with decreased cardiac output, prolonged hospital stay, and increased 6-month all-cause-mortality in patients with acute systolic heart failure.

BNP Levels and Diuretic Therapy

• 6 notes that BNP levels are influenced by age, gender, and body mass index, and can be elevated in various clinical settings, including cardiac and non-cardiac diseases.
• 7 found that marked elevations of BNP (>1,000pg/mL) are not generally seen in patients with heart failure and preserved ejection fraction (HFpEF), but can occur in patients with impaired renal function or relatively impaired systolic function.

Adding Lasix to HCTZ Treatment

• There is no direct evidence from the provided studies to support or refute the addition of Lasix to HCTZ treatment in a patient with a BNP level of 3,000.
• However, considering the patient's elevated BNP level and potential for fluid overload, adding a loop diuretic like Lasix may be beneficial in reducing fluid retention and improving symptoms, as long as renal function and electrolyte levels are closely monitored 4, 5.