Diuretics are a pillar of treating symptomatic volume overload in heart failure (HF), including at the end-of-life. Thiazide diuretics (e.g. hydrochlorothiazide, chlorthalidone) and potassium sparing diuretics (e.g. spironolactone) are well-known therapies for chronic HF, and loop diuretics such as furosemide or bumetanide are the mainstay for acute or severe HF.
For some patients the absorption and effectiveness of oral diuretics are reduced and intravenous diuretics are difficult to administer. In this situation, subcutaneous (SC) furosemide can be helpful.
The IV furosemide formulation is given via a SC clysis line for continuous subcutaneous infusions (CSCI) or a SC butterfly needle for intermittent dosing. For patients with an indwelling IV catheter, there is little rationale to utilize SC over IV.
- Current daily dose limits are approximately 200-300 mg daily.
- Onset of diuresis is 1-1.5 hours for oral, 30 minutes for S
C, and 5 minutes for IV furosemide.
- Diuretic effect is 6-8 hours for oral, 4 hours for SC
, and 2 hours for IV furosemide.
- Intermittent SC: start with an equivalent oral dose.
- CSCI dosing: calculate the initial hourly dose from the previous daily oral dose
E.g., a patient receiving 100 mg/day of oral furosemide should receive 100 mg SC in 24 hours or 4 mg/hr. CSCI.
Further research is needed but small clinical investigations have demonstrated effective diuresis with SC furosemide – it seems to be a role for its use in palliative care patients when oral treatment fails.
See reference for more information.
Adapted from Jozwiak R and Marks S. Subcutaneous diuretics for end-of-life management of heart failure. Palliative Care Network of Wisconsin. Fast facts and concepts #353. Internet. Accessed on April 28, 2018.