From the Guidelines
In this patient with rhabdomyolysis, sepsis, and heart failure with preserved ejection fraction (LVEF 55%) without volume overload, I recommend temporarily holding torsemide, Jardiance (empagliflozin), and Isordil (isosorbide dinitrate). These medications should be withheld until the acute illness resolves and renal function stabilizes. Torsemide and empagliflozin both increase the risk of acute kidney injury in the setting of rhabdomyolysis and sepsis, as noted in guidelines for heart failure management 1. Torsemide can worsen kidney injury by reducing renal perfusion, while empagliflozin can exacerbate volume depletion and electrolyte abnormalities. Isosorbide dinitrate should also be held as it can cause hypotension, which may worsen perfusion in a septic patient. Since the patient has a preserved ejection fraction without signs of volume overload, temporarily withholding these medications poses less cardiac risk. Close monitoring of vital signs, fluid status, and renal function is essential during this period, as emphasized in the management of heart failure 1. Once the patient recovers from the acute illness, these medications can be reintroduced sequentially, starting with the heart failure medications at lower doses and titrating as tolerated while monitoring renal function and hemodynamic stability. It's also important to consider the patient's overall clinical status and adjust the treatment plan accordingly, taking into account the latest guidelines for heart failure management 1.
From the FDA Drug Label
In patients with decompensated congestive heart failure, hepatic and renal clearance are both reduced, probably because of hepatic congestion and decreased renal plasma flow, respectively The total clearance of torsemide is approximately 50% of that seen in healthy volunteers, and the plasma half-life and AUC are correspondingly increased. Because of reduced renal clearance, a smaller fraction of any given dose is delivered to the intraluminal site of action, so at any given dose there is less natriuresis in patients with heart failure than in normal subjects
The patient has heart failure with an LVEF of 55% but does not appear to be volume overloaded. Torsemide should be used with caution in patients with heart failure, as its effectiveness may be reduced due to decreased renal clearance.
Ketoacidosis (increased ketones in your blood or urine). Ketoacidosis has happened in people who have type 1 diabetes or type 2 diabetes, during treatment with JARDIANCE. Ketoacidosis is a serious condition, which may need to be treated in a hospital.
Jardiance (empagliflozin) may increase the risk of ketoacidosis, particularly in patients with conditions that may increase this risk, such as sepsis.
Hemodynamic Effects The ill effects of isosorbide dinitrate overdose are generally the results of isosorbide dinitrate's capacity to induce vasodilatation, venous pooling, reduced cardiac output, and hypotension
Isordil (isosorbide dinitrate) can cause hypotension due to vasodilation, which may be problematic in patients with heart failure or those who are hypovolemic due to other conditions like sepsis.
Considering the patient's conditions (rhabdomyolysis, sepsis, and heart failure), it is recommended to exercise caution when continuing home medications, including torsemide, Jardiance, and Isordil. The patient's volume status, renal function, and cardiac output should be closely monitored. It may be necessary to adjust the doses or temporarily discontinue these medications to avoid potential adverse effects. 2, 3, 4
From the Research
Management of Home Medications
In a patient with rhabdomyolysis, sepsis, and heart failure with a left ventricular ejection fraction (LVEF) of 55% without signs of volume overload, the management of home medications such as torsemide, Jardiance (empagliflozin), and Isordil (isosorbide dinitrate) should be carefully considered.
- The decision to continue or discontinue these medications depends on various factors, including the patient's clinical condition, the severity of sepsis and heart failure, and the potential benefits and risks of each medication.
- According to a study published in the Journal of intensive care medicine 5, management of chronic heart failure medications warrants careful consideration for continuation or discontinuation upon development of sepsis.
- Torsemide, a loop diuretic, may be beneficial in patients with heart failure, especially those with edema, as it has a higher bioavailability and longer duration of action compared to furosemide 6, 7, 8.
- However, in the absence of volume overload, the need for torsemide may be reevaluated.
- Empagliflozin, an SGLT2 inhibitor, has been shown to have benefits in patients with heart failure, including reduced hospitalization and mortality 5.
- Isosorbide dinitrate, a nitrate, is commonly used in patients with heart failure to reduce symptoms and improve exercise tolerance.
- The continuation of these medications should be based on the patient's individual clinical condition and the potential benefits and risks of each medication.
Considerations for Medication Management
When managing home medications in a patient with sepsis and heart failure, the following considerations should be taken into account:
- The patient's volume status and the need for diuretics such as torsemide.
- The potential benefits and risks of continuing or discontinuing each medication.
- The severity of sepsis and heart failure and the need for adjustments in medication management.
- The patient's renal function and the potential impact of medications on kidney function.
- The potential interactions between medications and the need for close monitoring. As stated in the study published in the Heart failure reviews 9, management of patients with AHF and sepsis is challenging since cornerstone interventions for AHF may be contraindicated in sepsis and vice versa.