Does Furosemide need to be withheld or reduced in heart failure with impaired renal function?

From the Guidelines

Furosemide may need to be withheld or reduced in patients with heart failure and reduced eGFR, depending on the clinical situation, as indicated by the most recent guidelines from 2022 1.

Clinical Considerations

When managing patients with heart failure and reduced eGFR, it is crucial to balance the need for diuresis with the potential risks of worsening renal function.

• If a patient develops acute kidney injury, severe electrolyte abnormalities (particularly hypokalemia or hyponatremia), or shows signs of overdiuresis with symptoms like hypotension, dizziness, or worsening renal function, dose reduction or temporary discontinuation of furosemide is warranted.
• For patients with severely reduced eGFR (below 30 ml/min/1.73m²), higher doses of furosemide (80-160mg) may be needed due to reduced drug delivery to the site of action, but careful monitoring is essential, as highlighted in the 2016 ESC guidelines 1.

Monitoring and Adjustments

When adjusting furosemide, clinicians should monitor fluid status, blood pressure, electrolytes (especially potassium, sodium, and magnesium), and renal function regularly, as emphasized in the 2018 review on renal function monitoring in heart failure 1.

• Dose adjustments should be made gradually, typically reducing by 50% initially rather than abrupt discontinuation to prevent fluid rebound.
• The rationale for these adjustments is that while diuretics are crucial for managing fluid overload in heart failure, they can worsen renal perfusion by reducing intravascular volume and activating the renin-angiotensin-aldosterone system, potentially creating a vicious cycle of worsening kidney function, as discussed in the 2013 ACCF/AHA guideline 1.

Key Points

• Furosemide dose may need adjustment in patients with heart failure and reduced eGFR.
• Monitoring of renal function, electrolytes, and fluid status is essential when using furosemide in these patients.
• Gradual dose adjustments and careful monitoring can help mitigate the risks associated with furosemide use in patients with heart failure and reduced eGFR, as supported by the latest guidelines from 2022 1.

From the FDA Drug Label

If increasing azotemia and oliguria occur during treatment of severe progressive renal disease, Furosemide tablets should be discontinued. Abnormalities should be corrected or the drug temporarily withdrawn. Reversible elevations of BUN may occur and are associated with dehydration, which should be avoided, particularly in patients with renal insufficiency Furosemide tablets combined with angiotensin converting enzyme inhibitors or angiotensin II receptor blockers may lead to severe hypotension and deterioration in renal function, including renal failure. An interruption or reduction in the dosage of Furosemide tablets, angiotensin converting enzyme inhibitors, or angiotensin receptor blockers may be necessary

Yes, Frusemide (Furosemide) may need to be withheld or reduced in patients with heart failure and reduced eGFR.

• The dose of Furosemide may need to be adjusted in patients with renal insufficiency to avoid dehydration and worsening of renal function.
• Patients with severe progressive renal disease should be monitored closely, and Furosemide should be discontinued if increasing azotemia and oliguria occur.
• Concomitant use of Furosemide with other medications, such as angiotensin converting enzyme inhibitors or angiotensin II receptor blockers, may require interruption or reduction in dosage to avoid severe hypotension and deterioration in renal function 2.

From the Research

Diuretic Therapy in Heart Failure with Reduced eGFR

• The use of diuretics, such as frusemide, in patients with heart failure and reduced eGFR is a common practice to manage fluid overload and improve symptoms 3.
• However, the decision to start, uptitrate, or discontinue diuretic therapy in these patients can be challenging due to the potential risk of worsening renal function 3.

Effects of Frusemide on Renal Function

• Studies have shown that frusemide can increase urine volume, sodium, and potassium excretion in patients with chronic renal failure, without affecting intrinsic renal function 4.
• However, the combination of frusemide with other medications, such as angiotensin-converting enzyme inhibitors, can lead to a greater fall in mean blood pressure and an increase in cardiac output, but also a decrease in glomerular filtration rate 5.

Dosing and Monitoring of Frusemide

• There is no clear dosing recommendation for frusemide in patients with heart failure and reduced eGFR, but a low starting dose is often used 6.
• Monitoring of renal function, electrolytes, and fluid status is crucial when using frusemide in these patients to minimize the risk of adverse effects 7, 6.

Alternative Diuretic Strategies

• The use of high-dose loop diuretics or the addition of a thiazide diuretic, such as metolazone, may be considered in patients with refractory heart failure, but the risk of adverse effects, such as hypokalemia, hyponatremia, and worsening renal function, must be carefully weighed 7, 6.
• The choice of diuretic strategy should be individualized based on the patient's clinical condition, renal function, and response to treatment 3, 7, 6.