we know that the main theraphy of congestive heart failure with severe edema is furosemide. In one of my patient with congestive heart failure and severe edema, The patient is over 30 kg of her dryweigt. I gave 480 mg of furosmide and 25 mg of spiranolactone and HCTZ per day. In spite of this, I could not overcome the edema. So, I wonder what is the maximum dose of furosemide in severe congestive heart failure with renal failure (type 2 cardiorenal syndrome)?
Dear Mustafa,
Max furosemid dose usually 240mg/24h. There is most probably diuretic resistance. Try continuous furosemid or bumetanid infusion. If your patient has < 1L/24h urine output, you may consider renal replacement therapy.
Dear Eliana,
Firstly thanks a Lot for your kind answer. But I have already started hemodialysis and ultrafiltration.
The problem is that I could not continue hemodialysis because of paying problem.
in a manuscript I read that maximum dose of furosemide is 600 mg per day. But I don`t know it is true or not.
Up to 1 gm/day can be used. But if not responding to infusion of 10 mg/hr, according to my clinical experience there will be no benefit from huge doses.
Furosemide resistance is well known phenomenon with step-wise approach: Decrease salt intake, increase furosemide dose, shift to IV bolus then infusion and combination with other diuretics with different mechanism of action (e.g. Thiazide).
In case of hypoalbuminemia, expanding intravascular volume first then furosemide had been used (Those patients have more extravascular water than intravascular).
Some patients require haemofiltration at the end.
Also there is what is called Furosemide stress test (1-1.5 mg/kg)
https://www.ncbi.nlm.nih.gov/pubmed/25655065
Dear mustafa
I think that this patient has resistance of diuretics. Firstly you should do isole ultrafltration til dry Weight. After that patients heart may be relax especialy Afterload. Then you can recieve respond to furosemide. If you respond it .you should continue oral furosemid 500-1000 mg/day tablet. Good lucks
Dear Ashraf,
Thank you verry much for your answer. I am going to read mentioned manuscript above.
Dear Doctor Tatar,
thank you verry much for your exellent answer. I am going to do your recomentation for managment of that patient. But I wonder if there is a reference for dose of 500-1000 mg furosemide. if so, could you please send me the references. And also what do you think about tolvaptan use in that case?
Dear Dr Mustafa, I don't think increasing the dose of furosemide will help you. In this situation metolazone, a thiazide like diuretic will probably help. It, s diuretic action works in low GFR situation. Tolvaptan may also help if patient does not have hypernatremia. Following link might help you.. Thanks..
https://www.ncbi.nlm.nih.gov/pubmed/16189620
Dear Biswajit,
thank you for your answer.
But there is no methazolone preparation in our country.
There is no advantage in going above 200mg of frusemide daily. Try different class of diuretics in combination, to maximal dose.
Also look for compliance by the patient.
I want to share the last status of my patient. After 10 sesions of HD, her dry weight dropped to 69 kg. she started HD at the weight of 105 kg. she lost 36 kg. For 12 day without HD, dry weight has not been increased. The weight is now 69 kg today again. She is taking 4X120 mg of furosemide and 50 mg of HCTZ and spiranolactone as diuretic therapy. Her last kreatinin level was 1.5 mg/dL.
I have a question about minimum infusion rate in geriatric population..
The recommendation is to titrate to response in elderly but the starting dose was not mentioned!!
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