Management of Bronchitis in an 80-Year-Old with HFpEF on Dapagliflozin and Furosemide
Continue Current Medications Without Interruption
Continue dapagliflozin 10 mg daily throughout the bronchitis episode, as SGLT2 inhibitors are safe and beneficial in HFpEF patients with acute illness and do not require discontinuation during respiratory infections. 1, 2
- Dapagliflozin has demonstrated significant benefits in HFpEF, reducing hospitalizations for heart failure and improving quality of life, and should be maintained during acute illnesses unless hemodynamic instability develops 1, 2
- The drug is well-tolerated even in elderly patients with multiple comorbidities, and continuation during bronchitis poses no additional risk 3, 4
Continue furosemide 40 mg daily to maintain euvolemia, as diuretics remain essential for managing HFpEF even during respiratory infections. 1, 5
- The goal is to maintain the patient's "dry weight" while avoiding dehydration that could worsen renal function 1
- Monitor daily weights and adjust furosemide dose if signs of volume overload develop (weight gain >1 kg, increased dyspnea) 5
Optimize Antibiotic Therapy
Continue amoxicillin-clavulanate 650 mg three times daily for the full prescribed course (typically 7-10 days) for bacterial bronchitis with purulent sputum. 6
- Amoxicillin-clavulanate demonstrates 90.8% clinical and microbiological efficacy for lower respiratory tract infections with excellent tolerability 6
- Yellow sputum indicates bacterial infection requiring completion of antibiotic therapy 6
Address Positional Cough
The severe cough when lying down likely represents orthopnea from elevated pulmonary capillary wedge pressure rather than worsening bronchitis, requiring careful assessment for volume status. 7
- Check for other signs of volume overload: peripheral edema, jugular venous distension, weight gain, or increased dyspnea with exertion 1, 8
- If volume overload is present, increase furosemide to 60-80 mg daily and monitor response with daily weights (target 0.5-1.0 kg loss daily) 5
- If euvolemic, elevate head of bed 30-45 degrees and consider adding a cough suppressant for symptomatic relief 1
Critical Monitoring During Illness
Monitor renal function and electrolytes within 3-5 days, as acute illness combined with diuretics and SGLT2 inhibitors increases risk of volume depletion and electrolyte disturbances. 1, 5
- Check serum creatinine, BUN, sodium, and potassium 5
- Tolerate acute eGFR decreases up to 20-30% if patient remains clinically stable without signs of hypoperfusion 1
- If potassium >5.0 mEq/L, consider dietary restriction and potassium binder to maintain evidence-based therapies 1
Assess for signs of dehydration or hypoperfusion: orthostatic hypotension, decreased urine output, rising creatinine, or altered mental status. 1, 8
- If volume depletion occurs, temporarily reduce furosemide dose but do not discontinue dapagliflozin unless severe dehydration develops 5, 2
- Volume depletion rates with dapagliflozin are similar to placebo (7.3% vs 6.1%) and should not prompt routine discontinuation 3
Specific Management Algorithm
If patient has isolated cough without dyspnea or volume overload:
- Continue all current medications unchanged 1, 2
- Complete antibiotic course 6
- Elevate head of bed and consider antitussive therapy 1
- Recheck in 5-7 days to ensure resolution 8
If patient develops signs of volume overload (weight gain, worsening orthopnea, peripheral edema):
- Increase furosemide to 60-80 mg daily 5
- Continue dapagliflozin as it provides additive diuretic effect 9, 7
- Monitor daily weights with target loss of 0.5-1.0 kg daily 5
- Check electrolytes and renal function in 3-5 days 5
If patient develops hypotension (SBP <90 mmHg) or signs of hypoperfusion:
- Hold furosemide temporarily 8
- Continue dapagliflozin unless severe dehydration present 2
- Assess for sepsis or other acute complications 1
- Consider hospitalization if hypoperfusion persists 8
Common Pitfalls to Avoid
Do not discontinue dapagliflozin during acute respiratory illness unless severe hemodynamic instability or diabetic ketoacidosis develops. 1, 2
- SGLT2 inhibitors should be continued during COVID-19 and other infections as they do not increase infection risk 1
- Premature discontinuation eliminates the cardiovascular and renal protective benefits 1, 2
Do not over-diurese in response to positional cough, as this may represent baseline HFpEF physiology rather than acute decompensation. 1, 7
- Excessive diuresis can cause volume depletion, hypotension, and acute kidney injury 5
- Verify volume status with physical examination and daily weights before escalating diuretics 8
Do not stop antibiotics prematurely even if symptoms improve, as incomplete treatment increases risk of recurrence and resistance. 6