November 29, 2022

What Happened to My Furosemide? Torsemide for Congestive Heart Failure – Frankly Speaking EP 174

Nikkei is a 78 year old male with history of his first mi at age 63 he has had a second one three years ago that reduced his ejection fraction his cardiologist placed him on furosemide initially but recently switched him to tore some id nick is a little annoyed why did he change my medicine hi this is frank domino joining me today is dr. jill terian associate

Professor and director of the nurse practitioner program at the university of massachusetts medical school graduate school of nursing good morning jill good morning frank i’ve always been very hesitant about patients on heart failure and messing with their medicines especially if a cardiologist is involved i was a little surprised the cardiologist did this too

But now your patients asking you about it right so why don’t we talk a little bit about how heart failure is diagnosed okay so we need to remember that heart failure isn’t one condition it’s it’s it’s a it’s a finding that results in decreased blood flow to the patient and causing all sorts of symptoms it comes in both systolic and diastolic heart failure systolic

Heart failure is typically secondary to something that’s caused damage to the left ventricle making it less efficient so heart disease coronary artery disease is probably the most common post mi is where we see the majority of systolic dysfunction in heart failure diastolic dysfunction in heart failure is typically due to poor compliance of the left ventricle and

We see that from chronic poorly controlled hypertension decreasing the contract ability of the left ventricle great so that that was a great review so how do we typically manage it in the outpatient setting well most patients with heart failure have their primary condition treated so if they have coronary artery disease they’re typically on a statin maybe aspirin

And maybe some other platelet medications if their heart failure is due to hypertension their high blood pressure medications are there if it’s valvular disease or an arrhythmia like a fib those things need to be controlled the first and foremost you need to deal with the underlying condition next we know that patients all patients with our failure benefit from

Certain classes of medication ace inhibitors is one of them ace inhibitors have been a mainstay of treating heart failure for probably the last thirty years and we have really excellent data that shows having a patient with heart failure on an ace inhibitor provides you with improved mortality data number needed to treat around 25 beta blockers are also used for

Both diastolic and systolic dysfunction and heart failure this is a relatively newer player on the scene with with a similar outcome we have really good data that shows adding a beta blocker to a patient who’s stable in their heart failure decreases mortality and and so that that’s been quite common when patients have the adverse effects of poor outflow through the

Heart they’ll tend to get dependent edema congestive heart failure causing fluid in the lungs etc so diuretics have often been used and in particularly diuretics have often been used to help decrease the fluid that can build up in the lungs so those are the three main classes of drugs we have in the last 10 to 12 years added a different type of diuretic potassium

Sparing diuretic to the combination because there’s some pretty good data that shows it improves a variety of outcomes and should be used regularly when we’re treating it as long as the patient can tolerate it so nick is really he’s irritated that his cardiologist has done this because he was used to his furosemide so tell us a little bit about loop diuretics which

Are the mainstay of treatment and how does it differ from to us amide so sure osa might certainly what i was trained on it was it was commonly available i was probably been generic forever and it was what i always used with patients a recent systematic review had me rethink that it looked at outcomes in patients with heart failure and compared those who are on

Puros to those who are on taurus amide and taurus amide has some pharmaco therapeutic benefits it’s got a higher oral bioavailability and half-life therefore theoretically it should be you could probably do better with smaller amounts of meds but that was never really clearly proven so the systematic review compared nine randomized controlled trials and another

Ten observational studies looking at almost 20,000 patients and when they compared taurus amide it turned out those who are on tour some i’d has significantly fewer hospitalizations and you know we think about patients with heart failure this is often a fairly chronic and terminal condition so decreasing hospitalizations was really good the number needed to treat

Was very very favorable as well taurus amide also improved clinical functional status and this was a really important finding to me patients with heart failure often get very disabled because of their dyspnea and their fluid accumulation and that just leads to a downward spiral so improving functional status seemed like a good thing and sure enough the torso my

Group had improvements in their functional status far greater than those on furosemide those are two really great outcomes decreased hospitalization better symptom control and improved quality of life is is wonderful interestingly the tourists of my group also had a lower risk of cardiac mortality and that was that was very reassuring what was interesting was that

There was no difference between the furosemide and the taurus amide in all cause mortality or rate of side effects so you patients may not necessarily live longer but they’re gonna hopefully live better and and have fewer hospitalizations so it seems to me the switch from thorough so might the torso might makes good sense how would you do that frank what what is

The dosing schedule like and how does it compare the two drugs like anything else you have to titrate it to the patient but we have pretty good data that show a typical dose of hero so my 240 milligrams is equivalent in symptom control to about 20 milligrams of tor summize so it’s about you need a 50% less dose and i think you can take that up or down as you

Titrate it up or down with patients and that’s orally so it’s it’s pretty easy and being more effective and improving quality of life i think it’s worthwhile so we have to always think about the cost to our patients as well so do you know anything about the cost between throw some id and tourism id yeah so this was one of those things that piqued my interest when

This paper came out because i’ve been resistant to switch patients i didn’t realize there was a clinical benefit but i’ve always thought horsham id was a much more expensive medication it turns out a 30 day supply of 40 milligrams of furosemide is very inexpensive it’s five dollars it’s the cost of actually pouring pills into the bottle the medication is very very

Inexpensive tourists might now that it’s generic is also very inexpensive not quite as inexpensive if you buy it retail a 30-day supply can run anywhere from five to ten dollars so it’s not much more expensive if your patient has the latitude to add that extra cost i think making the switch makes good sense that is great information frank and something to consider

In in patients you want them to have a better quality of life so that is excellent thanks jill practice pointer in patients with heart failure horsham id improves functional status and reduces cardiac mortality compared to furosemide consider making that switch join us next time when we talk about pap smears and bimanual exams and adolescents

Transcribed from video
What Happened to My Furosemide? Torsemide for Congestive Heart Failure By Pri-Med