Loop diuretics for HFrEF

Loop diuretics can be used in patients with heart failure with reduced ejection fraction (HFrEF) to reduce the signs and symptoms of congestion (eg breathlessness, peripheral oedema) and improve exercise tolerance. At the time of writing, the effects of loop diuretics on mortality and morbidity have not been studied in placebo-controlled randomised controlled trials.

An increase in serum creatinine (a fall in estimated glomerular filtration rate [eGFR]) is commonly seen in patients with heart failure when they are started on a loop diuretic with a renin-angiotensin system inhibitor and/or a mineralocorticoid receptor antagonist. This should not necessarily prompt dose reduction or cessation of renin-angiotensin system inhibitor therapy. If the patient is euvolaemic, reduce the diuretic dose and monitor their weight, kidney function and serum electrolytes. If serum creatinine continues to rise, consider reducing the dose of the renin-angiotensin system inhibitor and/or mineralocorticoid receptor antagonist.

In patients with HFrEF, start with one the following doses of a loop diuretic and titrate to effect. Use:

If a patient develops HFrEF and is already taking a fixed-dose combination formulation containing a thiazide diuretic (hydrochlorothiazide or indapamide) with either an angiotensin converting enzyme inhibitor (ACEI) or an angiotensin II receptor blocker (ARB) for hypertension, replace the thiazide diuretic with a loop diuretic (and continue the ACEI or ARB). Loop diuretics are not available in fixed-dose combination tablets.