Furosemide for Heart Failure: High versus Low Dose, Bolus versus Infusion

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For patients with decompensated heart failure, the outcomes of loop diuretic therapy are similar at both high and low doses and with both bolus and continuous infusion, according to a report in the New England Journal of Medicine.

The multicenter Diuretic Optimization Strategies Evaluation (DOSE) trial included 308 patients with acute decompensated heart failure. In a two-by-two factorial design, patients were randomly assigned to receive intravenous furosemide in bolus doses or by continuous infusion; and in a low dose (equivalent to their previous oral dose) or a high dose (2.5 times the oral dose).

Specified dose adjustments were permitted after 48 hours. Patients assigned to bolus dosing were more likely to require a dose increase than those assigned to continuous infusion: 21 percent versus 11 percent. There was no difference in the need to switch to oral diuretics.

Global symptom ratings were not significantly different between the bolus and infusion groups. There was a trend toward greater symptom improvement in the high-dose group. The mean change in creatinine level was 0.08 mg/dL with high-dose and 0.04 mg/dL with low-dose furosemide.

Patients in the high-dose group had increased diuresis and improvement in some secondary outcomes. They also had a higher rate of transient decreases in renal function: 23 percent versus 14 percent. Serious adverse event rates were 38 and 50 percent, respectively.

The DOSE trial addresses the need for evidence to guide loop diuretic therapy for acute decompensated heart failure. The results showed similar symptoms and renal function outcomes with intravenous bolus dosing or continuous infusion and at high and low doses. The high-dose strategy may bring some additional improvement, but with more frequent worsening of renal function [Felker GM, et al. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med 2011; 364:797–805].