77-year-old female with history of chronic stage 4 kidney disease (CKD), insulin-dependent diabetes mellitus (IDDM), chronic obstructive pulmonary disease (COPD), and heart failure (HF) presents for follow-up of her HF. Patient takes 80 mg furosemide daily but still complains of increasing swelling in her legs. She was prescribed Bumex at her last visit, but has not started taking this medication. Patient has 4+ pitting edema with signs of capillary leak on exam, and there are crackles in bilateral lung bases. BNP is 3,095 and GFR is 13. What do you recommend?
HEALTHCASTS COMMUNITY RESPONSE
This patient case was posted to the Healthcasts peer-to-peer community in January/February 2020. 43 unique opinions were contributed. The case was reviewed and assessed in March 2020. The following is a summary of physician responses.
Initial steps: Adjust her medications, promote lifestyle changes
Ten (23%) respondents would add the thiazide diuretic Zaroxolyn® (metolazone) to her drug regimen for increased fluid removal. Four (9%) respondents would either increase the dose of Lasix (furosemide)—2 of the 43 (5%) respondents specified the increase of furosemide to 80 mg B.I.D.; or administer it via infusion. One respondent recommended starting her on Entresto® (sacubitril/ valsartan). Another suggested several lifestyle changes: low-sodium diet, legs raised whenever possible, avoiding anything that could make her congestive heart failure (CHF) worse. Another physician responded that the patient should have an echocardiogram.
“If this is ineffective, add metolazone and/or change to another loop diuretic.”
Echocardiogram to evaluate for structural cardiovascular causes
11 (25%) respondents recommend that an echocardiogram be obtained to evaluate the patient’s LVEF. In the patient’s presentation, the responding physicians learned that the patient did not start her course of oral Bumex® (bumetanide) as prescribed. Because her compliance is suboptimal, 16 (37%) respondents would want the patient admitted for monitoring and treatment. Plans for treatment ranged from IV diuresis (proposed by 8, i.e., 19% of the respondents) to dialysis (proposed by 21, i.e., 49% of respondents.
“Lack of ideal compliance with medical advice is a major concern.”
Consults with other specialists
11 (25%) respondents see the need to reach out for consults with either nephrologists, cardiologists, or both. Two (5%) respondents specifically pointed out that the patient needs counseling about her non-compliance. One physician who proposed initial outpatient treatment recommended more frequent visits, home healthcare nurse visits, and transmitted daily patient weights.
“Perhaps non-compliance with diet, daily weights, and sodium consumption is a problem as well.”