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How to prescribe loop diuretics in oedema

BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l359 (Published 21 February 2019) Cite this as: BMJ 2019;364:l359

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Re: How to prescribe loop diuretics in oedema

Dear Sir,
We were pleased to read your paper on “how to prescribe loop diuretics in oedema” [1]. Anisman et al. addressed a number of significant controversial “unanswered questions”. However a key “unanswered question” that has not been addressed is whether it is safe and effective to treat acute decompensated heart failure (HF) in the community or at home.

Small observation studies suggested outpatient based treatment in the community is safe and efficacious but these studies are prone to bias, eg 0% mortality was claimed in the BHF observation study [2], whereas 9.4% mortality was observed in the 2016/7 UK National Heart failure Audit [3]. Perhaps worryingly, outpatient based acute HF treatment has already grown in popularity in the UK even before the publication of a single randomised controlled trial (RCT) proving safety and effectiveness.

We sent an online survey that evaluated the use of outpatient based acute HF management to 237 consultant cardiologists with an interest in HF in the UK [4]. 50 (21%) completed the survey. We also included one other personal communication regarding the existence of ambulatory care providing outpatient based acute HF service. 13 (24%) indicated an outpatient based acute HF service was offered in the hospital where they worked; and 13 (24%) said their hospital/PCT supported a community based acute HF management service including the use of parenteral frusemide. Of the 13 community based acute HF services, delivery of the community parenteral frusemide service was provided by district nurses in 4 (31%), by HF nurses in 5 (38%); 2 (15%) were provided by “dedicated iv nurses”/ “community iv nurse-led team” supported by HF consultants” and 1 was provided by “hospital at home” (8%). 1 indicated “it depends” (8%). With regards to mode of delivery, 7 provided both iv and subcutaneous frusemide, whilst 2 provided subcutaneous frusemide only (delivered by HF nurses), and 2 provided iv frusemide only (2 did not answer this question).

A pilot RCT started recruitment in the Lancashire Cardiac centre to investigate the safety, clinical effectiveness and cost-effectiveness of outpatient based IV diuretic therapy in patients with decompensated HF. If the RCT confirms safety and effectiveness, then outpatient based acute HF management is likely to significantly expand in the next few years in the UK, increasing our ability to deliver safe patient-centred whole-person care, offering choice to patients and carers, as well as achieve significant cost-savings for the NHS.

List of references
1. Anisman SD, Erickson SB, Morden NE. How to prescribe loop diuretics in oedema. BMJ 2019 Feb 21;364:l359.

2. Treating heart failure patients in the Community with intravenous diuretics. https://www.bhf.org.uk/-/media/files/publications/healthcare-and-innovat... (last accessed 26th February 2019)

3. National Heart Failure Audit 2016/17 Summary report.
https://www.nicor.org.uk/wp-content/uploads/2018/11/Heart-Failure-Summar... (last accessed 26th February 2019).

4. Mohee K, Wong K. Are We Ready for Outpatient Acute Heart Failure Management (Frusemide Lounges and Beyond)?-A Nationwide Survey of UK Acute Heart Failure Practice. Heart 2016;102:A6-A7.

Kevin Mohee1
Kenneth Y-K Wong2

Author affiliation:
1. Department of Cardiology, Morriston Hospital, Swansea
2. Consultant Cardiologist with special interest in Heart Failure and Imaging, Cardiology Directorate Research Lead, Lancashire Cardiac Centre, Blackpool Victoria Hospital, Whinney Heys Rd, Blackpool FY3 8NR

Competing interests: No competing interests

27 February 2019
KENNETH Y-K WONG
Consultant Cardiologist with special interest in Heart Failure and Imaging, Cardiology Directorate Research Lead, Lancashire Cardiac Centre, Blackpool Victoria Hospital, Whinney Heys Rd, Blackpool FY3 8NR
Dr Kevin Mohee (Department of Cardiology, Morriston Hospital, Swansea)
Lancashire Cardiac Centre, Blackpool Victoria Hospital, Whinney Heys Rd, Blackpool FY3 8NR