Should I discontinue Lasix (furosemide) and add intravenous fluids to help flush out the elevated Creatine Kinase (CK) in a 67-year-old female patient with a history of heart failure with preserved ejection fraction (HPpEF) and bilateral leg swelling, who presents with right hip pain and normal renal function?

From the Guidelines

I would not recommend discontinuing Lasix (furosemide) in this patient with heart failure with preserved ejection fraction (HFpEF) and bilateral leg swelling who has elevated CK levels. Instead, maintain the Lasix while adding intravenous fluids at a controlled rate to help flush out the elevated CK. For IV fluids, consider normal saline at 75-100 mL/hour, carefully monitoring fluid status. This balanced approach addresses both concerns: the IV fluids will help clear the elevated CK and reduce the risk of kidney injury, while continuing Lasix prevents fluid overload that could worsen her heart failure symptoms.

The use of diuretics, such as Lasix, is recommended in patients with HFpEF who have evidence of fluid retention, unless contraindicated, to improve symptoms 1. Additionally, diuretics are the only drugs used for the treatment of hypertension and HF that can adequately control the fluid retention of HF, and their appropriate use is crucial to the success of other drugs used for the treatment of hypertension in the presence of HF 1.

Monitoring the patient's vital signs, daily weights, input/output, and renal function (BUN, creatinine) at least daily is essential, as well as tracking CK levels every 12-24 hours to assess clearance. The patient's normal baseline renal function is reassuring, but careful monitoring is essential to balance these competing concerns. It is also important to note that the use of loop diuretics, such as Lasix, can be associated with more severe renal decline, higher risk of hospital admission, and increased mortality rate, especially in patients with worsening renal function 1.

Therefore, a careful and balanced approach is necessary to manage this patient's condition, taking into account the potential risks and benefits of continuing Lasix and adding IV fluids. The goal is to prevent fluid overload, reduce the risk of kidney injury, and improve the patient's overall quality of life, while minimizing the risk of morbidity and mortality.

Some key points to consider in the management of this patient include:

• Careful monitoring of fluid status and renal function
• Balanced use of diuretics and IV fluids to prevent fluid overload and reduce the risk of kidney injury
• Regular tracking of CK levels to assess clearance
• Consideration of the potential risks and benefits of continuing Lasix and adding IV fluids
• A patient-centered approach that prioritizes the patient's quality of life and minimizes the risk of morbidity and mortality.

From the Research

Patient Management

• The patient has a history of heart failure with preserved ejection fraction (HPpEF) and presents with bilateral leg swelling, right hip pain, and elevated Creatine Kinase (CK) levels, but normal renal function.
• The use of Lasix (furosemide) in this patient may need to be reassessed, as it can affect renal function and potentially worsen the patient's condition 2.
• Adding intravenous fluids to help flush out the elevated CK levels may be considered, as fluid therapy can help prevent acute kidney injury (AKI) in patients with rhabdomyolysis 3, 4.

Fluid Management

• The goal of fluid therapy is to restore hemodynamic stability and vital organ perfusion while avoiding interstitial edema 4.
• Isotonic crystalloids should be the preferred agents for fluid therapy in patients with AKI, and balanced solutions may reduce the risk of hyperchloremic acidosis and kidney injury 4.
• The patient's fluid status should be closely monitored, and fluid management should be tailored to the individual patient's needs 4.

Elevated CK Levels

• Elevated CK levels can indicate rhabdomyolysis, which can lead to AKI and other complications 5.
• The patient's CK levels should be closely monitored, and treatment should be aimed at preventing further muscle damage and promoting renal function 2, 5.
• Discontinuation of any medications that may be contributing to the elevated CK levels, such as gemfibrozil, should be considered 6.

Renal Function

• The patient's normal renal function is a positive prognostic factor, as patients with initial estimated glomerular filtration rates (eGFR) > 60 mL/min/1.73 m(2) appear to be at a low risk of death or hemodialysis from rhabdomyolysis 5.
• However, the patient's renal function should still be closely monitored, as AKI can still occur even with normal initial renal function 5.