Combination Therapy with Metolazone and Loop Diuretics in Outpatients with Refractory Heart Failure: An Observational Study and Review of the Literature

Rosenberg, Jens; Gustafsson, Finn; Galatius, Søren; Hildebrandt, Per

doi:10.1007/s10557-005-3350-2

Cited by 80 publications

(47 citation statements)

References 24 publications

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“…In fact, most studies examining metolazone use in HF are small, single‐center retrospective analyses without a control arm, published over 25 years ago, that focused on end points like urinary volume and sodium concentration as opposed to clinical outcomes 8, 10, 28, 29. Nevertheless, the cumulative existing evidence in only 350 patients does illustrate that metolazone produces a 3‐fold increase in natriuresis, increases weight loss and improves diuresis in patients who were previously not suitable for hospital discharge 7, 8, 9, 10, 28, 29, 30…”

Section: Discussionmentioning

confidence: 99%

“…Both US and European Heart Failure (HF) guidelines state that when diuresis remains inadequate with loop diuretic therapy, either escalation of loop diuretic dose or the addition of a thiazide diuretic may be considered to intensify the regimen, yet these recommendation are based on limited data to support the relative safety of each appraoch 4, 5, 6. Notably, sequential nephron blockade further limits the ability of the kidney to regulate fluid and electrolyte excretion beyond loop diuretic monotherapy, potentially leading to complications such as hyponatremia, hypokalemia, and worsening renal function (WRF) 7, 8, 9, 10…”

Section: Introductionmentioning

confidence: 99%

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Outcomes Associated With a Strategy of Adjuvant Metolazone or High‐Dose Loop Diuretics in Acute Decompensated Heart Failure: A Propensity Analysis

Brisco‐Bacik

Maaten

Houser

et al. 2018

JAHA

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BackgroundIn acute decompensated heart failure, guidelines recommend increasing loop diuretic dose or adding a thiazide diuretic when diuresis is inadequate. We set out to determine the adverse events associated with a diuretic strategy relying on metolazone or high‐dose loop diuretics.Methods and ResultsPatients admitted to 3 hospitals using a common electronic medical record with a heart failure discharge diagnosis who received intravenous loop diuretics were studied in a propensity‐adjusted analysis of all‐cause mortality. Secondary outcomes included hyponatremia (sodium <135 mEq/L), hypokalemia (potassium <3.5 mEq/L) and worsening renal function (a ≥20% decrease in estimated glomerular filtration rate). Of 13 898 admissions, 1048 (7.5%) used adjuvant metolazone. Metolazone was strongly associated with hyponatremia, hypokalemia, and worsening renal function (P<0.0001 for all) with minimal effect attenuation following covariate and propensity adjustment. Metolazone remained associated with increased mortality after multivariate and propensity adjustment (hazard ratio=1.20, 95% confidence interval 1.04–1.39, P=0.01). High‐dose loop diuretics were associated with hypokalemia and hyponatremia (P<0.002) but only worsening renal function retained significance (P<0.001) after propensity adjustment. High‐dose loop diuretics were not associated with reduced survival after multivariate and propensity adjustment (hazard ratio=0.97 per 100 mg of IV furosemide, 95% confidence interval 0.90–1.06, P=0.52).ConclusionsDuring acute decompensated heart failure, metolazone was independently associated with hypokalemia, hyponatremia, worsening renal function and increased mortality after controlling for the propensity to receive metolazone and baseline characteristics. However, under the same experimental conditions, high‐dose loop diuretics were not associated with hypokalemia, hyponatremia, or reduced survival. The current findings suggest that until randomized control trial data prove otherwise, uptitration of loop diuretics may be a preferred strategy over routine early addition of thiazide type diuretics when diuresis is inadequate.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Outcomes Associated With a Strategy of Adjuvant Metolazone or High‐Dose Loop Diuretics in Acute Decompensated Heart Failure: A Propensity Analysis

Brisco‐Bacik

Maaten

Houser

et al. 2018

JAHA

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“…Bundan başka hipokalemi ve alkaloza bağlı olarak aritmi riskinin artışı, hipotansiyon gibi hemodinamik instabiliteye neden olmaları yanında lipid profilinde bozulma, hiperürisemi ve ototoksisite gibi birçok olumsuz etkileri kalp yetmezliğinde diüretikleri zan altında bırakmaktadır. Diüretikler nörohumoral aktivasyonu daha da artırmakla da suçlanmakta ve tüm bu sebepler klinisyenleri kalp yetmezliğinde hipervolemi tedavisinde diüretiklere alternatif tedaviler bulmaya itmektedir (23)(24)(25). Bu tedavinin diüretiklere alternatif olabilmesi için etkin olduğu kadar güvenli de olması gerekir.…”

Section: Kalp Yetmezliğinde Volüm Fazlalığının Patogeneziunclassified

Ultrafiltration Treatment in Heart Failure

Altunören¹,

Güngör²,

Yılmaz³

2016

Turk Neph Dial Transpl

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özKalp yetmezliği genel popülasyonda sık görülen bir hastalık olup ciddi morbidite ve mortalite sebebidir. Tedavide su ve tuz kısıtlamasının yanında temel olarak diüretikler kullanılmaktadır. Ancak diüretik tedavisine yetersiz cevap ve bazı yan etkileri diüretiklerin kullanımlarını kısıtlamaktadır. Ayrıca diüretiklerin kalp yetmezliğinin patogenezinde yer alan nörohumoral aktivasyonu artırdığı da düşünülmektedir. Ultrafiltrasyon, su ve solütlerin konvektif klerensi temeline dayanan bir tedavi yöntemidir ve kalp yetmezliği tedavisinde diüretiğe dirençli olgularda uzun zamandır kullanılmaktadır. Bu derlemede ultrafiltrasyon tedavisinin kalp yetmezliği tedavisindeki yeri irdelendi. AnAhtAR sözcükleR: Diüretik, Kalp yetmezliği, Periton diyalizi, Ultrafiltrasyon AbstRActHeart failure is a common disorder in the general population and causes serious mortality and morbidity. Diuretic agents are generally used in addition to salt and water restriction in its treatment. However, an insufficient response and some adverse affects restrict the usage of diuretics. Furthermore, it is believed that diuretic agents also increase neurohumoral activation that has been cited in the pathogenesis of heart failure. Ultrafiltration is a treatment method based on the convective clearance of water and solutes and has been used for a long time in the treatment of diuretic-resistant heart failure. In this review article, we discuss the place of ultrafiltration in the treatment of heart failure.

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“…U komparaciji sa niskodoznom strategijom, visokodozna strategija je bila ipak udružena sa većim poboljšanjem sekundarnih ciljeva, uključujući dispneju, ali po cenu češćeg tranzitornog pogoršanja bubrežne funkcije. Kod bolesnika sa rezistentnim perifernim edemima (i ascitesom), potrebna je kombinacija diuretika Henleove petlje, spironolactona i tiazida (i tiazidima sličnih diuretika -metolazon, indapamid) da bi se postigla adekvatna diureza (sekvencijalna blokada nefrona) [14,15] (tabela 2). Kombinacije diuretika su potentne, ali zahtevaju pažljivo praćenje (monitoring) da bi se izbegla hipokaliemija, hipomagnezemija, renalna disfunkcija i hipovolemija.…”

Section: Diureticiunclassified

What is new in the diagnostics and treatment of acute heart failure?

Bastać¹,

Jelenković²,

Joksimović³

et al. 2015

Tim Med Glas

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(1) INTERNISTIČKA ORDINACIJA "DR BASTAĆ", ZAJEČAR, (2) PEDIJATRIJSKA SLUŽBA ZC ZAJEČAR, (3) INTERNISTIČKA ORDINACIJA "JOKSIMOVIĆ", BOR, (4) INTERNISTIČKA SLUŽBA, ZC ZAJEČAR Sažetak:Srčana insuficijencija se definiše kao nenormalnost srčane strukture ili funkcije koja dovodi do nesposobnosti srca da isporuči kiseonik brzinom koja je adekvatna zahtevima metabolizma u tkivima, uprkos normalnom pritisku punjenja srca. Najčešći uzroci akutne srčane insuficijencije (ASI) jesu oboljenja miokarda koja dovode do ventrikularne disfuncije i sniženja ejekcione frakcije srca (EF) i abnormalnosti dijastolne funkcije. U suspektnoj ASI postoje 2 pristupa za egzaktnu dijagnozu: putem korišćenja brzih eseja za B tip natriuretskih peptidnih hormona (BNP i NT-pro-BNP) ili putem ehokardiografskog pregleda sa merenjem ejekcione frakcije ili dijastolnih anomalija i hipertrofije miokarda. Dijagnoza i lečenje se izvode paralelno. Stalni monitoring pacijentovih vitalnih funkcija je esencijalan za vreme inicijalne evaluacije i lečenja, i izvesni pacijenti se najbolje leče u intenzivnoj ili koronarnoj jedinici. Dugotrajni ciljevi lečenja su prevencija rekurentne ASI i poboljšanje prognoze. Simultano se procenjuje 5 aspekata: adekvatnost ventilacije, prisustvo ugrožavajućih aritmija, stanje tenzije, prisustvo akutnog koronarnog sindroma i akutni mehanički razlozi. Promene u strategiji lečenja, na osnovu novih preporuka ESC, jeste lečiti što pre i što brže akutnu srčanu insuficijenciju, analogno lečenju akutnih koronarnih sindroma. Po novoj strategiji, treba rano uvesti terapiju za protekciju ciljnih organa: srca, jetre i bubrega putem ranog davanja dovoljne doze vazodilatatora i dekongestivnu terapiju kombinacijom diuretika, što se smatra ključnim u prevenciji mortaliteta i brzog reagovanja prema prisustvu ugrožavajućeg stanja, kao što je, na primer, hitna revaskularizacija i dr. Ključni lekovi u ASI su : oksigenoterapija, diuretici i vazodilatatori, i novi lek koji obećava, serelaksin. Ključne reči: akutna srčana insuficijencija, B tip natriuretskih peptidnih hormona (BNP), ehokardiografija, ejekciona frakcija, oksigenoterapija, diuretici, vazodilatatori, serelaksin.

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Combination Therapy with Metolazone and Loop Diuretics in Outpatients with Refractory Heart Failure: An Observational Study and Review of the Literature

Abstract: The literature review and the observational study support the use of low-dose metolazone (< or =5 mg) on top of oral loop diuretics, as an effective and relatively safe treatment in contemporary outpatients with refractory HF.

Cited by 80 publications

References 24 publications

Outcomes Associated With a Strategy of Adjuvant Metolazone or High‐Dose Loop Diuretics in Acute Decompensated Heart Failure: A Propensity Analysis

Outcomes Associated With a Strategy of Adjuvant Metolazone or High‐Dose Loop Diuretics in Acute Decompensated Heart Failure: A Propensity Analysis

Ultrafiltration Treatment in Heart Failure

What is new in the diagnostics and treatment of acute heart failure?

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