Note when using diuretics in the treatment of heart failure

The article was professionally consulted by MSc Vu Thi Tuyet Mai - Cardiologist - Cardiovascular Center - Vinmec Central Park International General Hospital. The doctor has over 13 years of experience in the diagnosis and treatment of cardiovascular diseases.

Use of diuretics in the treatment of heart failure helps to reduce symptoms of blood stasis and peripheral edema. Diuretics come in many forms and are indicated for use in different patients. However, the use of diuretics in the treatment of heart failure can cause some unwanted effects.

1. Diuretic drug groups

Diuretics have the effect of increasing urine volume, helping to increase the excretion of Na + and H2O in the extracellular fluid.
Diuretics include 3 groups:
K+-sparing diuretics: aldosterone antagonists (Spironolactone), Amiloride, triamterene. K+-lowering diuretics: Loop diuretics (Furosemide), CA inhibitors (Acetazolamide) and Thiazides (Hydrochlorothiazide). Osmotic diuretic: Mannitol.

Thuốc lợi tiểu có tác dụng làm tăng khối lượng nước tiểu

2. Diuretics commonly used in the treatment of heart failure

2.1. Thiazides

This is the drug of first choice for patients with mild heart failure, chronic heart failure. Treatment is usually started at a low dose, then gradually increased in patients with severe heart failure before switching to loop diuretics or in combination. If renal function is reduced, the effectiveness of thiazide diuretics will be reduced.
In current treatment, Thiazides are often used in combination with ACE inhibitors, or angiotensin II receptor blockers, to increase efficiency and inhibit the activation of the renin-angiotensin system caused by Thiazides.

2.2. Furosemide

Furosemide is often indicated for patients with severe heart failure, helping to lose sodium quickly, effectively even in patients with low glomerular filtration rate.
In patients with severe heart failure, the absorption of furosemide is slow, the renal response is also reduced, the drug has a maximum effect after 4 hours. To increase response, the frequency of administration should be increased with the target dose.
The bioavailability and half-life of Furosemide are not appreciated compared with treatment with bumetanide and torsemide. The number of times the drug is administered per day depends on the half-life. The half-life of Furosemide is short (from 1 to 2 hours), so it must be administered several times a day.
If the patient has concomitant renal impairment, higher doses of Furosemide are usually needed to achieve the desired diuretic effect.

2.3. Aldosterone antagonists

Spironolactone is indicated in combination with a thiazide and a loop diuretic to prevent electrolyte disturbances in the majority of patients with heart failure. In addition, Spironolacton also inhibits myocardial fibrosis and reduces the risk of developing heart failure, reducing the risk of death for patients with heart failure.

Thuốc kháng aldosterone giúp ngăn ngừa rối loạn điện giải

3. Note when using diuretics in the treatment of heart failure

3.1 When should it be used?

Diuretics are recommended for patients with congestive heart failure. Particularly, anti-aldosterone diuretics are indicated for patients with NYHA class II-IV heart failure with an EF ≤ 35% or patients with an EF 40% after an acute MI, with symptoms of heart failure.
When used, it is necessary to understand 4 characteristics:
Diuretic dose response in patients with heart failure Pharmacokinetics of loop diuretics Correlation between diuretic dose and effectiveness The phenomenon of diuretic resistance.

3.2 The phenomenon of resistance to diuretics

Patients can become resistant to diuretics in 2 forms:

3.2.1 Short-term greasy

That is, decreased response to diuretics after the first dose. The mechanism underlying this condition is unknown, but may be due to sympathetic nervous system or angiotensin II activation.

3.2.2 Long-term greasy

With prolonged use of loop diuretics, fluid from the loop of Henle escapes into the distal renal tubule, causing hypertrophy and increased sodium absorption. Therefore, sodium released from the loop of Henle is reabsorbed in the distal tubule, reducing the effectiveness of the drug.

Nhờn thuốc — Bệnh nhân có thể bị nhờn thuốc lợi tiểu

3.3 Drug interactions

Do not combine thiazides with loop diuretics. K+-sparing diuretics when combined with K+-increasing drugs should be carefully monitored If diuretics are used with NSAIDs, there may be an increased risk of acute renal failure. To achieve good treatment results, avoid unwanted effects, treatment patients need to absolutely follow the doctor's instructions.

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