Downloaded from http://spcare.bmj.com/ on September 17, 2015 - Published by group.bmj.com
Letter
THE USE OF FUROSEMIDE IN HEART FAILURE SYMPTOM RELIEF It is important to recognise that the lack of evidence suggested for subcutaneous furosemide is equally applicable to any route of delivery for furosemide. This means that there are no placebo-controlled randomised trials demonstrating the longer-term benefits of furosemide (irrespective of its administration route) in terms of morbidity and mortality in heart failure. Indeed, there is a discrepancy in the analysis of the evidence for the grade 1 recommendation for furosemide (ie, evidence, and or general agreement, that a treatment or procedure is benefi cial, useful, effective) suggested both by American and European guidelines in heart failure. The European Society of Cardiology guideline 3 suggests the level of evidence is ‘B’ (ie, limited populations evaluated. Data derived from a single randomised trial or from non-randomised studies), whereas, the American Heart Association 1 evaluates the same evidence as ‘C’ (ie, very limited populations evaluated. Only consensus opinions of experts, case studies or standards of care).
THE EFFICACY AND DOSING OF SUBCUTANEOUS FUROSEMIDE
We read with interest the editorial concerning the use of subcutaneous furosemide in heart failure. We feel that there is substantial opportunity for misinterpretation of the editorial by readers not as familiar with the issues raised as the eminent authors themselves. This particularly relates to:
The argument in favour of this practice is clearly documented by the authors. Difficulties in dosing subcutaneous diuretics should be taken within the similar uncertainties existing for the administration of any diuretic irrespective of its route. The most recent (and only randomised large-scale trial of diuretics in decompensated heart failure) suggest no substantial clinical difference between dose size or frequency of administration of intravenous diuretics for decompensated heart failure.4 There is no reason to suspect that this lack of clear efficacy of any single intravenous diuretic regime should not equally apply to subcutaneously administered furosemide. Additionally, it is not unusual within the evidence-based practice of heart failure to extrapolate evidence into populations not represented within that evidence, for example, the majority of ACE inhibitors and B blocker trials have populations entirely unrepresentative of clinically encountered populations.5
HEART FAILURE SYNDROME
CLINICAL EXPERTISE AND PATIENT VALUES
It is important to emphasise that the editorial relates to the treatment of congestive symptoms in patients with the heart failure syndrome irrespective of its causal mechanism, that is, left ventricular systolic dysfunction is only one of the many mechanisms inducing this syndrome. This means that 50% of patients hospitalised with heart failure do not have left ventricular systolic dysfunction.1 2
Heart failure is not a diuretic deficiency disease. Therefore, the use of increasing doses of diuretics, their need for titration, measures of their success and the need for other cardiac and non-cardiac interventions to reduce symptoms should all occur within the framework of a multidisciplinary heart failure programme (irrespective of the route of administration of the augmented diuretic).1 3 Our own practice, specifically with regard to
Response to editorial on subcutaneous diuretics
84
BMJ Supportive & Palliative Care June 2012 Vol 2 No 2
Downloaded from http://spcare.bmj.com/ on September 17, 2015 - Published by group.bmj.com
Letter subcutaneous diuretics, is to use professionals skilled in the management of congestive symptoms to regularly titrate the dose of subcutaneous diuretics until a prespecified goal or end point is reached. Weight reduction is only one feature of this assessment. It should be noted that in a registry of over 100 000 patients hospitalised with heart failure onethird of patients lost < 2.3 kg, and 16% gained weight over their entire hospitalisation.2 While we agree with the authors that there is a need for further evaluation of the use of subcutaneous furosemide in the management of advanced heart failure (indeed we are seeking to add to the evidence base in this area), we feel that it may be unhelpful to isolate only this area of heart failure management for comment. We hope that in placing the editorials concerns within the context of available knowledge of current heart failure practice, clinicians will feel able to continue to use the subcutaneous route of administration when this promotes patient choice in the management of their progressive chronic illness. Duwarakan Satchithananda,1 Angela Ingram,2 Claire Hookey3 1 Department of Cardiology, University Hospital of North Staffordshire, Stoke-on-Trent, UK 2 Staffordshire and Stoke-on-Trent Partnership NHS Trust, Stoke-on-Trent, UK 3 Douglas Macmillan Hospice, Stoke-on-Trent, UK
Correspondence to Dr Duwarakan Satchithananda, University Hospital of North Staffordshire, Cardiology, Stoke-on-Trent st4 6qg, UK; [email protected]
Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed. Accepted 3 April 2012 BMJ Supportive & Palliative Care 2012;2:84–85. doi:10.1136/bmjspcare-2012-000259
REFERENCES 1.
2. 3.
4. 5.
Hunt SA, Abraham WT, Chin MH, et al. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 2009;119:e391–e479. Gheorghiade M, Filippatos G. Reassessing treatment of acute heart failure syndromes: the ADHERE Registry. Eur Heart J Suppl 2005;7:B13–B19. Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the diagnosis and treatment of acute and chronic heart failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur J Heart Fail 2008;10:933–989. Fonarow GC. Comparative effectiveness of diuretic regimens. N Engl J Med 2011;364:877–878. Lenzen MJ, Boersma E, Reimer WJ, et al. Underutilization of evidence-based drug treatment in patients with heart failure is only partially explained by dissimilarity to patients enrolled in landmark trials: a report from the Euro Heart Survey on Heart Failure. Eur Heart J 2005;26:2706–2713.
BMJ Supportive & Palliative Care June 2012 Vol 2 No 2
85
Downloaded from http://spcare.bmj.com/ on September 17, 2015 - Published by group.bmj.com
Response to editorial on subcutaneous diuretics Duwarakan Satchithananda, Angela Ingram and Claire Hookey BMJ Support Palliat Care 2012 2: 84-85
doi: 10.1136/bmjspcare-2012-000259 Updated information and services can be found at: http://spcare.bmj.com/content/2/2/84.2
These include:
References Email alerting service
This article cites 5 articles, 2 of which you can access for free at: http://spcare.bmj.com/content/2/2/84.2#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Letter
THE USE OF FUROSEMIDE IN HEART FAILURE SYMPTOM RELIEF It is important to recognise that the lack of evidence suggested for subcutaneous furosemide is equally applicable to any route of delivery for furosemide. This means that there are no placebo-controlled randomised trials demonstrating the longer-term benefits of furosemide (irrespective of its administration route) in terms of morbidity and mortality in heart failure. Indeed, there is a discrepancy in the analysis of the evidence for the grade 1 recommendation for furosemide (ie, evidence, and or general agreement, that a treatment or procedure is benefi cial, useful, effective) suggested both by American and European guidelines in heart failure. The European Society of Cardiology guideline 3 suggests the level of evidence is ‘B’ (ie, limited populations evaluated. Data derived from a single randomised trial or from non-randomised studies), whereas, the American Heart Association 1 evaluates the same evidence as ‘C’ (ie, very limited populations evaluated. Only consensus opinions of experts, case studies or standards of care).
THE EFFICACY AND DOSING OF SUBCUTANEOUS FUROSEMIDE
We read with interest the editorial concerning the use of subcutaneous furosemide in heart failure. We feel that there is substantial opportunity for misinterpretation of the editorial by readers not as familiar with the issues raised as the eminent authors themselves. This particularly relates to:
The argument in favour of this practice is clearly documented by the authors. Difficulties in dosing subcutaneous diuretics should be taken within the similar uncertainties existing for the administration of any diuretic irrespective of its route. The most recent (and only randomised large-scale trial of diuretics in decompensated heart failure) suggest no substantial clinical difference between dose size or frequency of administration of intravenous diuretics for decompensated heart failure.4 There is no reason to suspect that this lack of clear efficacy of any single intravenous diuretic regime should not equally apply to subcutaneously administered furosemide. Additionally, it is not unusual within the evidence-based practice of heart failure to extrapolate evidence into populations not represented within that evidence, for example, the majority of ACE inhibitors and B blocker trials have populations entirely unrepresentative of clinically encountered populations.5
HEART FAILURE SYNDROME
CLINICAL EXPERTISE AND PATIENT VALUES
It is important to emphasise that the editorial relates to the treatment of congestive symptoms in patients with the heart failure syndrome irrespective of its causal mechanism, that is, left ventricular systolic dysfunction is only one of the many mechanisms inducing this syndrome. This means that 50% of patients hospitalised with heart failure do not have left ventricular systolic dysfunction.1 2
Heart failure is not a diuretic deficiency disease. Therefore, the use of increasing doses of diuretics, their need for titration, measures of their success and the need for other cardiac and non-cardiac interventions to reduce symptoms should all occur within the framework of a multidisciplinary heart failure programme (irrespective of the route of administration of the augmented diuretic).1 3 Our own practice, specifically with regard to
Response to editorial on subcutaneous diuretics
84
BMJ Supportive & Palliative Care June 2012 Vol 2 No 2
Downloaded from http://spcare.bmj.com/ on September 17, 2015 - Published by group.bmj.com
Letter subcutaneous diuretics, is to use professionals skilled in the management of congestive symptoms to regularly titrate the dose of subcutaneous diuretics until a prespecified goal or end point is reached. Weight reduction is only one feature of this assessment. It should be noted that in a registry of over 100 000 patients hospitalised with heart failure onethird of patients lost < 2.3 kg, and 16% gained weight over their entire hospitalisation.2 While we agree with the authors that there is a need for further evaluation of the use of subcutaneous furosemide in the management of advanced heart failure (indeed we are seeking to add to the evidence base in this area), we feel that it may be unhelpful to isolate only this area of heart failure management for comment. We hope that in placing the editorials concerns within the context of available knowledge of current heart failure practice, clinicians will feel able to continue to use the subcutaneous route of administration when this promotes patient choice in the management of their progressive chronic illness. Duwarakan Satchithananda,1 Angela Ingram,2 Claire Hookey3 1 Department of Cardiology, University Hospital of North Staffordshire, Stoke-on-Trent, UK 2 Staffordshire and Stoke-on-Trent Partnership NHS Trust, Stoke-on-Trent, UK 3 Douglas Macmillan Hospice, Stoke-on-Trent, UK
Correspondence to Dr Duwarakan Satchithananda, University Hospital of North Staffordshire, Cardiology, Stoke-on-Trent st4 6qg, UK; [email protected]
Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed. Accepted 3 April 2012 BMJ Supportive & Palliative Care 2012;2:84–85. doi:10.1136/bmjspcare-2012-000259
REFERENCES 1.
2. 3.
4. 5.
Hunt SA, Abraham WT, Chin MH, et al. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 2009;119:e391–e479. Gheorghiade M, Filippatos G. Reassessing treatment of acute heart failure syndromes: the ADHERE Registry. Eur Heart J Suppl 2005;7:B13–B19. Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the diagnosis and treatment of acute and chronic heart failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur J Heart Fail 2008;10:933–989. Fonarow GC. Comparative effectiveness of diuretic regimens. N Engl J Med 2011;364:877–878. Lenzen MJ, Boersma E, Reimer WJ, et al. Underutilization of evidence-based drug treatment in patients with heart failure is only partially explained by dissimilarity to patients enrolled in landmark trials: a report from the Euro Heart Survey on Heart Failure. Eur Heart J 2005;26:2706–2713.
BMJ Supportive & Palliative Care June 2012 Vol 2 No 2
85
Downloaded from http://spcare.bmj.com/ on September 17, 2015 - Published by group.bmj.com
Response to editorial on subcutaneous diuretics Duwarakan Satchithananda, Angela Ingram and Claire Hookey BMJ Support Palliat Care 2012 2: 84-85
doi: 10.1136/bmjspcare-2012-000259 Updated information and services can be found at: http://spcare.bmj.com/content/2/2/84.2
These include:
References Email alerting service
This article cites 5 articles, 2 of which you can access for free at: http://spcare.bmj.com/content/2/2/84.2#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
