Weight Chart (For Heart Failure Patients) (Page 2 of 2) in pdf

June 2009

RxFiles Q&A - DRAFT

Furosemide Oral “Sliding Scale” in Heart Failure (HF)

1,2,3

Sample Dosing Ideas for Managing Otherwise Stable HF Patients

1 This type of diuretic dosing self-adjustment: A) is only suitable for select patients (e.g. who are not already over-diuresed

and B) will

(e.g right sided failure; liver disease with worsening cardiac output)

require individualization depending especially on threshold for furosemide dose to attain diuresis and if significant renal function impairment

. Ideally, guidance for

(CrCl <30ml/min )

all dose changes would be provided by a heart failure clinic or experienced health care practitioner.

2 Example covers furosemide dosing but addition of daily metolazone or hydrochorothiazide may also be more useful in some patients than furosemide dose increase.

3 Patients whose potassium levels tend to be low, may need to start or ↑ K+ supplementation

(e.g. fruit juices, bananas; Slow K

, Micro-K

, K-Dur

, K-10 Solution, K-Lyte

)

8 MEq

20 MEq

25MEq

4 In general, increasing ACE inhibitor

and beta blocker

dosages toward maximally tolerated can improve both morbidity and mortality

eg. ramipril, lisinopril, enalapril

eg. bisoprolol, carvedilol, metoprolol

outcomes. Reduction in diuretic (e.g. furosemide) dose in stable patients is often required to achieve these optimal doses and improve heart function and cardiac output.

Instructions regarding adjustment of oral furosemide dosing for changes in dry weight or symptoms (e.g.

breathlessness or increasing edema) reflecting a change in fluid status or possible precipitation of acute HF.

Note: A little edema may actually be a good thing as this is a buffer between dry weight and fluid overload!

Caution: Furosemide is not to be over used for managing slight swelling of the ankles & legs.

If WEIGHT INCREASES more than 1 kg (or 2 lbs) over 2 days (or 2.5kg over 5 days)…

evaluate for PRECIPITATING FACTORS:

{e.g. overindulgence in SALTY foods, herbs (e.g. alfalfa, dandelion, ginseng, hawthorn, nettle), use of

OTC or Rx

NSAIDS (such as ibuprofen

, celecoxib, etc.), other drug causes (new drug or new drug dosage;

CCBs such as verapamil, diltiazem, nifedipine) or inter-current illness (pneumonia, anemia etc.).}

If not currently taking daily

If already on furosemide: increase each dose of furosemide

furosemide: Start furosemide

by an additional

_20 -

40mg.

_20 - 40mg

once daily

e.g. If on 20mg daily, ↑ to 40mg daily (or 20mg twice daily).

in the morning.

If on 40mg daily, ↑ to 80mg daily (or 40mg twice daily).

If on 20mg twice daily, ↑ to 40mg twice daily.

{Some HF patients may only need

(at breakfast & noon).

}

If on 40mg twice daily, ↑ to 80mg twice daily.

occasional short-term furosemide

{Twice daily administration provides extra benefit for some HF patients.}

treatment for acute exacerbations.}

Reassess fluid status in 2-3 days. May need to consider potassium status &

possible need for supplements or renal panel

after 2-3 days.

e.g. Na+, K+, SCr

If dry weight not achieved or symptoms not subsided.

If dry weight achieved

Increase each dose of furosemide by

__40mg__

& symptoms subsided.

for the next 2-3 days. Then Reassess.

consider return to original

furosemide dose.

e.g. If on 40mg daily, ↑ to 80mg daily (or 40mg twice daily).

If on 80mg daily, ↑ to 120mg daily (or 80mg in am & 40mg at noon).

However if there are ≥ 2 episodes of

If on 40mg twice daily, ↑ to 80mg twice daily

fluid overload in a 3 week period,

If on 80mg twice daily, ↑ to 120mg twice daily.

consider a permanent increase in

furosemide dose until overall drug

therapy can be reassessed by

If dry weight not achieved or symptoms not subsided,

physician/specialist.

seek further physician assessment and advice.

Need for hospital admission should be assessed.

If WEIGHT DECREASES by ≥ 1 kg (2 lbs) over 2 days, or ≥ 2.5kg (5 lbs) over 5 days…

Dry weight refers to ideal body weight, or weight without extra

consider decreasing furosemide dose in

_20-40mg____

water accumulation / edema. Often done 1

thing in the morning,

steps every 2-3 days until weight stable (at dry weight).

in the nude, after emptying bladder, before or after bathing.

{If on K+ supplement, reassess K+ status / possible dose reduction.}

Some ankle edema at the end of the day is normal. It may

Note: dizziness and thirst may also reflect dehydration

respond to putting feet/legs up (e.g. reclining or lying down). This

can be useful to do 30-60 minutes before bedtime if night-time

and need for furosemide dose reduction.

shortness of breath. Compression stockings may be helpful in

{Occasionally, physician assessment of sodium, potassium, SCr & BUN lab tests

some, however are contraindicated in symptomatic HF.

may be useful in further assessing fluid status.}

Medscape

CVToolkit:

;

: 10 steps before you refer

;

Weight Chart (For Heart Failure Patients) Page 2

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