Safe medication use: Understanding diuretics in heart failure

MK is a 68-year-old female who was recently diagnosed with heart failure. She was presented to the hospital with worsening swelling in both feet, coughing, and shortness of breath. Upon discharge, among her new prescriptions for the management of heart failure was Furosemide, with specific instructions (e.g., weighing herself every morning). She wondered why this medication requires specific instructions.

Furosemide is a loop diuretic, commonly referred to as a “water pill” that is used to manage heart failure symptoms. Since loop diuretics are symptom-driven, they should be regularly assessed and adjusted to the optimum effective dose. For patients like MK, a loop diuretic is frequently required to help them manage their symptoms, such as swelling in the feet (edema) and shortness of breath (dyspnea). However, as with all medications, diuretics carry potential side effects and there are important considerations for safe medication use. This article will review key information and practical tips to support safe and effective use of diuretics.

How do diuretics work?

In heart failure, the heart cannot pump blood efficiently, leading to fluid backup and volume overload. Diuretics clear excess salt and water that cause fluid overload, reducing swelling, and relieving the heart’s workload. The main diuretic used in this case is a loop diuretic, such as, Furosemide. Although diuretics do not cure heart failure, they are essential for controlling fluid, improving comfort, and helping patients stay out of the hospital when used carefully and monitored regularly.

Common side effects of diuretics

While highly effective, diuretics require a balanced act because they could lead to electrolyte disturbances, worsening kidney function, and volume depletion. Hypokalemia (i.e., low potassium) is a common side effect. If patients with heart failure experience signs of volume depletion, such as dizziness, stable weight dropping below their baseline, or excessive fatigue, their diuretic dose may need to be reduced to protect their kidneys. The overarching strategy for dosing diuretics in managing heart failure is to find the lowest possible dose that could keep the patient symptom-free.

Self-care practices and safe medication use considerations

Managing heart failure starts with effective patient education and knowledge to empower their self-care practices. An example of self-care management is daily weigh-ins at home first thing in the morning after going to the washroom to assess the need for diuretic dose adjustment. Other self-care symptom-management strategies include eliminating or reducing alcohol use to less than two drinks per week, undertaking regular exercise (e.g., walking, cycling, swimming, light weight lifting), and implementing good sleep hygiene practices (e.g., avoiding caffeine late in the day, relaxing activities like mindfulness or reading, eliminating or reducing screen time one hour before bed, using low-intensity warm lighting, etc.). Reducing salt intake (https://www.who.int/news-room/fact-sheets/detail/sodium-reduction) to less than 5 g per day (i.e., just under one teaspoonful or less than 2000 mg/day of sodium) also helps reduce fluid retention in the body. This can be achieved by reducing consumption of pre-made foods, salty snacks, and reviewing nutrition information on labels before buying.

Pharmacists in the community play a vital role in supporting patients to safely self-adjust their diuretic doses based on their daily tracking and monitoring (https://pmc.ncbi.nlm.nih.gov/articles/PMC6739659/). In an outpatient setting, they are available to perform regular medication reviews with patients, and provide education and information on side-effect management, self-monitoring, dietary and lifestyle modifications to improve patient’s quality of life. It is also important to note that if heart failure symptoms are not improving within 1-2 days of adjusting the diuretic dose (under the directions or recommendations of your primary care clinician), contact your prescriber, pharmacist, or visit an urgent care clinic for professional guidance and follow-up.

For MK, once her weight returns to her usual baseline, and her swelling and shortness of breath improve, her Furosemide dose could be lowered. This would help reduce the risk of removing too much fluid from her body, which may lead to dehydration and electrolyte imbalances. If MK’s condition remains stable, Furosemide may sometimes be taken on an as-needed basis, especially when other heart failure medications are optimized to help maintain her fluid balance. Through collaborating with patients, pharmacists are in an optimal position to monitor patients with heart failure in the community, support their self-care management and self-managed titrations or adjustments to help optimize medication doses, improve symptoms, overall health, and medication safety.

A helpful tool for patients to initiate a conversation with their primary care clinicians is by using the Institute for Safe Medication Practices Canada (ISMP Canada) “5 Questions to Ask About Your Medications” (https://www.ismp-canada.org/download/MedRec/MedSafety_5_questions_to_ask_poster.pdf), which could help facilitate discussions with healthcare professionals during regular follow-up appointments and at times of patient consultation at the pharmacy.

Angela Choi and Sarah Plank are PharmD Students at the Leslie Dan Faculty of Pharmacy, University of Toronto; and Certina Ho is an Assistant Professor, Teaching Stream, at the Leslie Dan Faculty of Pharmacy and Department of Psychiatry, University of Toronto.

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