Association of lower urinary tract symptoms and diuretic adherence

OBJECTIVE

To assess whether more severe urinary symptoms and poorer quality of life among patients on diuretic therapy are associated with decreased adherence to the diuretic regimen.

METHODS

Participants were recruited via ResearchMatch.org and sent a REDCap survey. The Overactive Bladder Questionnaire-Short Form (OAB-q SF) was used to assess urinary symptom bother and health-related quality of life (HRQL). Participants were asked if they skip diuretic doses due to urinary symptoms with a bivariate (yes or no) outcome. Subgroup analyses of loop vs non-loop diuretic and those taking the diuretic for a cardiovascular indication (hypertension or heart failure) were performed.

RESULTS

A total of 4029 surveys were sent, 285 were returned (7.1% response rate), and 279 were included in the study. Fifty-three participants admitted to skipping diuretic doses due to urinary symptoms. Lower HRQL scores were significantly associated with poorer adherence scores among all participants (P < .001), among participants taking a loop diuretic (P < .001), and among participants with hypertension and heart failure (P < .039). Association between symptoms and adherence remained significant after adjustment in the multivariate model for the whole cohort and loop diuretic subgroup but lost significance in the hypertension and heart failure subgroup.

CONCLUSIONS

Worsening quality of life due to urinary symptoms may be associated with poorer adherence to diuretics, particularly loop diuretics.

Impact of the COVID-19 pandemic on cardiovascular heart disease medication use: time-series analysis of England's prescription data during the COVID-19 pandemic (January 2019 to October 2020)

BACKGROUND

Management of high blood pressure (BP) typically requires adherence to medication regimes. However, it is known that the COVID-19 pandemic both interrupted access to some routine prescriptions and changed some patient health behaviours.

AIM

This study, therefore, retrospectively investigated prescription reimbursement of cardiovascular (CVD) medicines as a proxy measure for patient adherence and access to medicines during the pandemic.

METHODS

A cohort study of all primary care patients in England prescribed CVD medicines. The exposure was to the global pandemic. Prescriptions were compared before and after the pandemic's onset. Statistical variation was the outcome of interest.

RESULTS

Descriptive statistics show changes to monthly prescriptions, with wide confidence intervals indicating varying underlying practice. Analysis of variance reveals statistically significant differences for bendroflumethiazide, potassium-sparing diuretics, nicorandil, ezetimibe, ivabradine, ranolazine, colesevelam and midodrine. After the pandemic began (March-October 2020), negative parameters are observed for ACE inhibitors, beta-blockers, calcium channel blockers, statins, antiplatelet, antithrombotics, ARBs, loop diuretics, doxazosin, bendroflumethiazide, nitrates and indapamide, indicating decelerating monthly prescription items (statistically significant declines of calcium channel blockers, antithrombotic, adrenoreceptor blockers and diuretics) of CVD medicines within the general population. Many data points are not statistically significant, but fluctuations remain clinically important for the large population of patients taking these medications.

CONCLUSION

A concerning decline in uptake of CVD therapies for chronic heart disease was observed. Accessible screening and treatment alongside financial relief on prescription levies are needed. A video abstract is (4 min 51 s) available: https://bit.ly/39gvEHi.

Loop diuretic down-titration in stable chronic heart failure is often achievable, especially when urinary chloride concentration is low

BACKGROUND

This study investigates spot urinary chloride concentration in euvolemic chronic heart failure (CHF) patients.

METHODS

This prospective cohort study included 50 ambulatory CHF patients on maintenance loop diuretics without recent hospital admission, clinical signs of volume overload, or adjustment in neurohumoral blocker or diuretic therapy. Spot urinary samples were collected immediately after loop diuretic intake. Subsequently, loop diuretic dose was reduced with 50% or stopped if ≤40 mg furosemide equivalents. Successful down-titration was defined as persistent dose reduction after 7 d without body weight increase >1.5 kg.

RESULTS

Urinary chloride concentration was 3045 ± 1271 mg/L overall. Patients with higher versus lower urinary chloride concentrations took the same dose of loop diuretics [40 mg (20-40 mg) furosemide equivalents; p value = .509] and had similar plasma NT-proBNP levels [1179 ng/L (311-2195 ng/L) versus 900 ng/L (255-1622 ng/L), respectively; p value = .461]. Down-titration was successful in 72% versus 76%, respectively (p value  = 1.000). At 30 d, loop diuretic dose remained reduced in 59% versus 76% of patients, respectively (p value = .238). The proportion of patients free from diuretic therapy was 45% versus 62% in the high versus low chloride concentration group (p value = .265).

CONCLUSIONS

Loop diuretic down-titration was successful in 3 out of 4 euvolemic CHF patients, irrespectively of urinary chloride concentration on spot samples collected after diuretic intake.

Development of Tolerance to Chronic Intermittent Furosemide Therapy in Pediatric Patients

OBJECTIVES

The purpose of this study is to describe whether tolerance develops in pediatric patients receiving chronic intermittent furosemide therapy, to characterize when it occurs and whether age-related variations exist. The effects of increasing total daily dose of furosemide and concurrent diuretics and vasopressors were assessed as secondary aims.

METHODS

Charts from patients receiving intravenous or oral furosemide for at least 3 consecutive days of therapy between June 1, 2013, and December 31, 2013, were reviewed retrospectively. Daily net fluid balance was used as the objective marker for development of tolerance. Net fluid balance (mL/kg/mg) was defined as the difference in a patient's daily intake and urine output (mL), normalized by weight (kg) and total daily dose of furosemide (mg).

RESULTS

Sixty-one patients, aged 2 days to 20 years (median 3 years), were included in this study. Median daily dose of furosemide was 1.96 mg/kg/day (range, 0-13.7 mg/kg/day). Average net fluid balance for all patients on the first day and last day of therapy was 6.83 and 26.66 mL/kg/mg, respectively (p = 0.011). Linear regression and Spearman's correlation found no significant relationship between age and difference in net fluid balance between the first and last day. Linear mixed-effects model for net fluid balance with day as covariate found that net fluid balance increases over time (p = 0.002).

CONCLUSIONS

Pediatric patients appear to develop tolerance to chronic intermittent furosemide therapy.

Loop diuretics for patients receiving blood transfusions

BACKGROUND

Blood transfusions are associated with significant morbidity and mortality. Prophylactic administration of loop diuretics (furosemide, bumetanide, ethacrynic acid, or torsemide) is common practice, especially among people who are at risk for circulatory overload, pulmonary oedema or both.

OBJECTIVES

This review aimed to determine if the prophylactic administration of loop diuretics (furosemide, bumetanide, ethacrynic acid, or torsemide) provides a therapeutic advantage (that is, a favourable risk benefit ratio) in adults and children who are recipients of any blood product transfusion versus placebo, no treatment, or general fluid restriction measures.

SEARCH METHODS

We searched the Cochrane Renal Group's Specialised Register to 13 January 2015 through contact with the Trials' Search Co-ordinator using search terms relevant to this review.

SELECTION CRITERIA

All randomised controlled trials (RCTs) and quasi-RCTs assessing a loop diuretic in patients receiving any blood transfusion were considered for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality and extracted data. Study authors were contacted for additional information. Results were to be expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. Mean effect sizes were to be calculated using the random-effects models.

MAIN RESULTS

We included four studies that involved 100 participants. Furosemide was the only diuretic investigated in all four studies.None of the included studies assessed the clinically important outcomes noted in our protocol. The studies focused on various markers of respiratory function. An improvement in fraction of inspired oxygen (in favour of furosemide) was noted in one study. An improvement in pulmonary capillary wedge pressure (in favour of furosemide) was noted in two studies.

AUTHORS' CONCLUSIONS

There was insufficient evidence to determine whether premedicating people undergoing blood transfusion with loop diuretics prevents clinically important transfusion-related morbidity. Due to the continued use of prophylactic loop diuretics during transfusions, and because this review highlights the absence of evidence to justify this practice, well-conducted RCTs are needed. Given the high mortality, severe morbidity and increasing incidence of transfusion-associated circulatory overload, determining the therapeutic utility of pre-transfusion loop diuresis is an urgent need.