Many Heart Failure Patients Might Safely Reduce Use of Diuretics

FRIDAY, May 31, 2019 -- Heart failure is a common ailment afflicting older Americans, and many take drugs called diuretics to rid the body of excess fluid buildup that can impede breathing.

Now, a team of Brazilian researchers say that, in some cases, it's safe for patients with stable heart failure to stop taking diuretic drugs.

"Patients don't like using diuretics because they feel they have to stay at home to use the bathroom and they get cramps," noted study principal investigator Dr. Luis Rohde, of the Federal University of Rio Grande do Sul in Porto Alegre, Brazil.

"Patients would welcome being able to stop this medication," he said, and the new study suggests it can often be done safely.

One U.S. expert who reviewed the new findings stressed that diuretics are key to heart failure care.

"Congestive heart failure is one of the most common chronic ailments in the United States, characterized primarily by volume (fluid) overload," explained Dr. Mohammed Imam. In heart failure, a damaged or weakened heart fails to pump blood as efficiently as it should.

"The mainstay of treatment for decades have been diuretics," said Imam, who directs cardiothoracic surgery at The Heart Institute at Staten Island University Hospital in New York City. Diuretics help patients with heart failure reduce excess fluids that can cause shortness of breath, swollen legs, coughing and weight gain.

However, the Brazilian team noted that prior studies have also found long-term diuretic use to be linked with worse patient outcomes.

So, can diuretic use be safely reduced? To find out, Rohde's team tracked outcomes for 188 outpatients in Brazil with stable chronic heart failure who were taking the diuretic furosemide.

The patients were randomly selected to either keep taking the drug (the "maintenance" group) or to start taking an inactive placebo instead (the "withdrawal" group). The patients did not know if they were still taking furosemide or not.

Over the next 90 days, there was no difference between the two groups in patient-reported shortness of breath, the team reported.

Also, 72 patients (75%) in the withdrawal group and 78 patients (84%) in the maintenance group did not require furosemide reuse during the 90-day follow-up, the study authors said. The findings were reported this week at a meeting of the European Society of Cardiology, in Athens, Greece.

"Heart failure patients have many pills to take for their heart failure and for [other illnesses], such as diabetes and hypertension," Rohde said in a society news release. "Withdrawing one drug when it is no longer necessary should make it easier to take the ones that are needed," he added.

According to study senior author Andreia Biolo, "The results show that patients with stable heart failure who stop diuretics do not have more (shortness of breath) than those who continue taking the drug." Biolo is also with the Federal University of Rio Grande do Sul.

"Withdrawal also does not lead to increased reuse of diuretics -- [only] around 20% of patients in both groups needed a top-up, presumably for symptom relief," Biolo noted in the news release.

Overall, the study also found that "patients can be followed-up in the usual way," she said. "And, as we do now, patients should be educated to seek medical help if they become breathless, get edema [swelling], or have sudden weight gain, which indicates fluid retention."

But Imam wasn't convinced that diuretics can be eliminated so easily.

In his experience, "even if patients miss diuretics for a few doses, they get recurrent symptoms and feel better almost immediately on resuming them, even in patients with stable heart failure," he said.

Imam believes the study "is a radical diversion from traditional thinking and most clinicians would … continue using diuretics to treat stable congestive heart failure."

But another U.S. heart failure specialist was more encouraged by the Brazilian findings.

Dr. Marrick Kukin directs heart failure care at Lenox Hill Hospital in New York City. He agreed that "diuretic withdrawal in heart failure patients is an important goal."

Kukin said, "If it can be done safely, patients are more comfortable (less urination), and there is less jeopardy to the kidney."

But the new study involved a relatively small number of patients, so a larger trial may be needed to settle these questions. Findings presented at medical meetings are also considered preliminary until published in a peer-reviewed journal.

In the meantime, a more nuanced approach to diuretics may work best, Kukin believes.

"In my practice, with savvy patients who can recognize symptoms and take their weight daily, I empower them to make daily diuretic decisions," he said.

While a long-term "fixed" dose of diuretics might not be necessary, the Brazilian trial did not give patients the flexibility "to make daily adjustments" to the dose of diuretic they might require, Kukin noted. For many heart failure patients, that may be the best course to take, he suggested.