Yet Another Diuretic for Acute Heart Failure
Volume 24, Issue 2
These past few months have been fruitful in the field of diuretic research. In a prior column, we covered a recent clinical trial evaluating 2 different thiazide diuretics for treating essential hypertension. This trial showed there was no difference between hydrochlorothiazide and chlorthalidone with respect to blood pressure control or rates of major adverse cardiac events.
We also evaluated a trial comparing torsemide vs furosemide for managing congestion in patients with acute heart failure. Again, there was no difference noted between the two drugs with respect to cardiovascular death or heart failure hospitalization.
Lastly, the ADVOR trial recently showed acetazolamide was efficacious in augmenting decongestion when added to a loop diuretic regimen in patients with acute heart failure.
In this week’s issue of Talking Therapeutics, we explore yet another trial evaluating diuretic therapy in patients with acute heart failure.
Point 1: Pros and Cons to Adding Thiazides
The CLOROTIC trial randomized patients hospitalized with acute decompensated heart failure to receive hydrochlorothiazide (n=114) or placebo (n=116) for 5 days in addition to background furosemide therapy. The dose of hydrochlorothiazide was based on estimated glomerular filtration rate and ranged from 25 mg daily to 100 mg daily.
While more patients in the hydrochlorothiazide group had a greater change in weight at 96 hours, there were no differences in all-cause mortality or rehospitalization at 30 days between groups. Furthermore, there was a higher rate of worsening renal function within the treatment group. The trial was stopped early in 2019 due to poor enrollment.
Point 2: There Likely Are Better Options
When comparing the CLOROTIC study to the ADVOR trial, we can see that both drugs augment diuresis, but acetazolamide did not worsen renal function or cause electrolyte disturbances. If one was pressed to select a second diuretic to add to furosemide, it would likely be acetazolamide and not a thiazide.
However, neither acetazolamide nor hydrochlorothiazide improved rates of death and hospitalization for heart failure. SGLT2 inhibitors do provide these benefits to patients with heart failure, and they can also augment decongestion in the setting of acute heart failure. Therefore, the second drug added to furosemide in acute heart failure should probably not be another diuretic, but rather a SGLT2 inhibitor.
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