What are the indications for Metolazone (a thiazide-like diuretic)?

From the Guidelines

Metolazone is primarily indicated for the treatment of edema associated with heart failure, particularly in patients with resistant edema who have not responded adequately to loop diuretics alone, as evidenced by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. The indications for metolazone, a thiazide-like diuretic, can be summarized as follows:

• Treatment of hypertension
• Treatment of edema associated with heart failure, renal dysfunction, and hepatic cirrhosis
• Use in patients with resistant edema who have not responded adequately to loop diuretics alone
• Creation of a powerful sequential nephron blockade effect when combined with loop diuretics like furosemide, enhancing diuresis in patients with severe fluid overload Typical dosing ranges from 2.5 to 10 mg once daily, with lower doses (2.5-5 mg) often used for hypertension and higher doses for edema, as recommended in the 2013 ACCF/AHA guideline for the management of heart failure 1.

Key Considerations

• Metolazone works by inhibiting sodium and chloride reabsorption in the distal tubule of the kidney, leading to increased excretion of sodium, water, chloride, potassium, and bicarbonate
• Due to its long half-life and risk of electrolyte disturbances, careful monitoring of fluid status, electrolytes (particularly potassium), and renal function is essential during treatment
• Patients should be advised about potential orthostatic hypotension, especially when initiating therapy

Clinical Use

• Metolazone may be added to loop diuretics in patients with refractory edema unresponsive to loop diuretics alone, as stated in the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1
• The treatment goal of diuretic use is to eliminate clinical evidence of fluid retention, using the lowest dose possible to maintain euvolemia
• Diuretics should be prescribed to patients who have evidence of congestion or fluid retention, and maintenance diuretics should be considered to avoid recurrent symptoms 1

From the FDA Drug Label

INDICATIONS AND USAGE Metolazone is indicated for the treatment of salt and water retention including: • edema accompanying congestive heart failure; • edema accompanying renal diseases, including the nephrotic syndrome and states of diminished renal function Metolazone is also indicated for the treatment of hypertension, alone or in combination with other antihypertensive drugs of a different class.

The indications for Metolazone are:

• Edema accompanying:
  • Congestive heart failure
  • Renal diseases, including the nephrotic syndrome and states of diminished renal function
• Hypertension, alone or in combination with other antihypertensive drugs of a different class 2

From the Research

Indications for Metolazone

The indications for Metolazone, a thiazide-like diuretic, include:

• Edema and/or ascites in patients with hepatic cirrhosis or nephrotic syndrome 3
• Renal failure and the nephrotic syndrome, where it can help with loss of edema and improved control of blood pressure 4
• Hypertension, where it can significantly reduce systolic and diastolic blood pressure 5
• Acute decompensated heart failure, where it can be used as an adjuvant therapy to increase diuresis, although its use is associated with increased risk of adverse events such as hyponatremia, hypokalemia, and worsening renal function 6

Specific Patient Populations

Metolazone can be used in various patient populations, including:

• Patients with chronic renal insufficiency, where it can be used for long-term diuretic therapy 4
• Patients with mild to moderate hypertension, where it can be used as a safe and effective therapy 5
• Patients with acute decompensated heart failure, where it can be used as an adjuvant therapy, although its use should be carefully considered due to the increased risk of adverse events 6