From the Guidelines
For patients with heart failure who have a lasix (furosemide) allergy, bumetanide (0.5-2 mg daily) or torsemide (10-100 mg daily) are recommended as alternative loop diuretics, as they have different chemical structures and may be tolerated despite a furosemide allergy. When considering alternative diuretics, it's essential to understand the mechanisms and effects of different classes of diuretics, as outlined in the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. This guideline provides a comprehensive overview of the treatment of congestion for chronic heart failure, including the use of loop diuretics and thiazide diuretics.
Key Considerations for Diuretic Therapy
- The aim of using diuretics is to achieve and maintain euvolaemia, with the lowest achievable dose, as stated in the ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 1.
- Loop diuretics, such as bumetanide and torsemide, produce a more intense and shorter diuresis than thiazides, which cause a more gentle and prolonged diuresis.
- Thiazide diuretics, like hydrochlorothiazide (12.5-50 mg daily) or metolazone (2.5-10 mg daily), may be less effective in patients with reduced kidney function, but can be used in combination with loop diuretics to treat resistant oedema.
- The doses of commonly used diuretics are provided in the guidelines, with initial and usual daily doses ranging from 0.5-2 mg for bumetanide and 10-100 mg for torsemide.
Additional Heart Failure Medications
- Incorporate standard heart failure medications, including ACE inhibitors (like lisinopril 5-40 mg daily), ARBs (such as losartan 25-100 mg daily), beta-blockers (metoprolol succinate 25-200 mg daily), and aldosterone antagonists (spironolactone 12.5-50 mg daily), as recommended in the guidelines 1.
- For advanced heart failure, consider SGLT2 inhibitors like dapagliflozin (10 mg daily), which have been shown to improve outcomes in patients with heart failure.
Monitoring and Adjustments
- Before starting alternative diuretics, confirm the nature of the lasix allergy, as true allergies are rare while side effects are common.
- Monitor kidney function, electrolytes, and blood pressure closely when initiating these medications, as diuretic therapy can affect these parameters.
- Adjust the dose of diuretics based on the patient's response, with the goal of achieving and maintaining euvolaemia, as stated in the guidelines 1.
From the FDA Drug Label
Bumetanide injection is indicated for the treatment of edema associated with congestive heart failure, hepatic and renal disease, including the nephrotic syndrome. Successful treatment with bumetanide following instances of allergic reactions to furosemide suggests a lack of cross-sensitivity.
Treatment Option: Bumetanide can be used to treat heart failure in patients with a Lasix (furosemide) allergy, as it is indicated for the treatment of edema associated with congestive heart failure and suggests a lack of cross-sensitivity with furosemide.
- Key Point: Bumetanide may be administered orally or parenterally (intramuscularly or intravenously) depending on the patient's condition and absorption capabilities. 2
From the Research
Treatment Options for Heart Failure with Lasix Allergy
- For patients with heart failure and a Lasix (furosemide) allergy, alternative diuretic options can be considered, such as metolazone or other loop diuretics 3, 4.
- Metolazone, a thiazide-like diuretic, can be used in combination with a loop diuretic to enhance diuresis in patients with refractory heart failure 4, 5.
- However, metolazone has been associated with increased risk of hyponatremia, hypokalemia, and worsening renal function 3.
- High-dose loop diuretics may be a preferred strategy over routine early addition of thiazide-type diuretics when diuresis is inadequate, as they are not associated with reduced survival 3.
- The choice of diuretic should be guided by patient clinical situations and the presence of other co-morbidities 6.
Considerations for Diuretic Therapy
- Diuretic resistance is a common issue in heart failure patients, and adding thiazide-type diuretics like metolazone can be an effective strategy to overcome this resistance 5.
- The 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure provides recommendations for diuretic therapy in heart failure patients, including the use of metolazone and other diuretics 7.
- It is essential to monitor patients closely for adverse effects, such as electrolyte imbalances and renal dysfunction, when using diuretics to treat heart failure 3, 4, 6, 5.