(1/x) What is the best diuretic to use for hospitalized patients? 🏥
(hint: its not just furosemide)
A 🧵 on multimodal diuresis
#foamed #medtwitter #diuretics x.com
(hint: its not just furosemide)
A 🧵 on multimodal diuresis
#foamed #medtwitter #diuretics x.com
(2/x) Furosemide (or a similar loop diuretic) is my backbone of diuresis for most hospitalized patients ... but it has some problems.🏥
The good:
1) Effective at both natriuresis (sodium excretion) and aquaresis (water excretion)
2) Cheap
3) Effective at decongestion
4) High familiarity
The bad:
1) Short acting (6h) - this means that for inpatients BID or TID dosing should be routine
2) It may fail at getting adequate natriuresis (sodium excretion)... diuresis without natriuresis is less effective at decongesting patients
3) It predictably causes 1) hypernatremia 2) elevated HCO3 3) low K+.
The ugly:
1) People confuse the expected electrolyte abnormalities of furosemide (high Na, high HCO3, and low K+) with being a reflection of volume status. I see people who have been biochemically "overdiuresed" that still have SEVERE venous congestion on organ level Doppler
The solution?
Multimodal diuresis.
The good:
1) Effective at both natriuresis (sodium excretion) and aquaresis (water excretion)
2) Cheap
3) Effective at decongestion
4) High familiarity
The bad:
1) Short acting (6h) - this means that for inpatients BID or TID dosing should be routine
2) It may fail at getting adequate natriuresis (sodium excretion)... diuresis without natriuresis is less effective at decongesting patients
3) It predictably causes 1) hypernatremia 2) elevated HCO3 3) low K+.
The ugly:
1) People confuse the expected electrolyte abnormalities of furosemide (high Na, high HCO3, and low K+) with being a reflection of volume status. I see people who have been biochemically "overdiuresed" that still have SEVERE venous congestion on organ level Doppler
The solution?
Multimodal diuresis.
(3/x) The theory behind multimodal diuresis is that by using multiple classes of diuretics we can optimize diuresis, natriuresis, and decongestion while minimizing side effects of the medication.
This essentially separates the biochemical changes of diuresis from 'volume status'.
So what do drugs do we have to use on top of furosemide?
1) Thiazide Like Diuretics - e.g. Metolazone, HCTZ, chlorthalidone, indpamide
2) Acetazolamide
3) Spironolactone (or other MRAs)
Here's my approach 👇
This essentially separates the biochemical changes of diuresis from 'volume status'.
So what do drugs do we have to use on top of furosemide?
1) Thiazide Like Diuretics - e.g. Metolazone, HCTZ, chlorthalidone, indpamide
2) Acetazolamide
3) Spironolactone (or other MRAs)
Here's my approach 👇
(4/x) My approach to multimodal diuresis is:
1) Lasix backbone for everyone dosed BID or TID (whatever dose you think your patient needs, consider doubling it).
2) Look for reasons to add Metolazone or Acetazolamide
3) If sodium is already high (or increasing with diuresis), add Metolazone to augment natriuresis. This is highly effective in decongestion and preventing hypernatremia
4) If the HCO3 is climbing in response to diuresis and the patient is becoming alkalotic, introduce acetazolamide into your diuretic regime.
5) If you have hypernatremia and constantly are chasing your K+, consider adding a MRA (be careful of renal function).
Of course, these strategies should always be integrated into the appropriate clinical context.
1) Lasix backbone for everyone dosed BID or TID (whatever dose you think your patient needs, consider doubling it).
2) Look for reasons to add Metolazone or Acetazolamide
3) If sodium is already high (or increasing with diuresis), add Metolazone to augment natriuresis. This is highly effective in decongestion and preventing hypernatremia
4) If the HCO3 is climbing in response to diuresis and the patient is becoming alkalotic, introduce acetazolamide into your diuretic regime.
5) If you have hypernatremia and constantly are chasing your K+, consider adding a MRA (be careful of renal function).
Of course, these strategies should always be integrated into the appropriate clinical context.
(5/x) Some cautions for a multimodal diuretic strategy ❌
1) Order your 'extra' diuretics for only a few doses at a time - this strategy requires regular reassessment or you can get some severe electrolyte abnormalities
2) You don't have to correct a pts. volume status or congestion in a day. Slow and steady.
3) If you don't know what you are doing, you can cause problems with this. (I have seen some overshooting and people ending with HCO3 of 10 from acetazolamide)
1) Order your 'extra' diuretics for only a few doses at a time - this strategy requires regular reassessment or you can get some severe electrolyte abnormalities
2) You don't have to correct a pts. volume status or congestion in a day. Slow and steady.
3) If you don't know what you are doing, you can cause problems with this. (I have seen some overshooting and people ending with HCO3 of 10 from acetazolamide)
What other pearls does the #foamed community have here?
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