Diamox IV for heart failure?

[EMEDPA]

Diamox in heart failure. Is anyone doing this?

https://rebelem.com/the-advor-trial-acetazolamide-in-acute-decompensated-heart-failure/?utm_source=rss&utm_medium=rss&utm_campaign=the-advor-trial-acetazolamide-in-acute-decompensated-heart-failure

[polarbebe]

In my ICU, have tried it in select patients… can’t say I have seen a dramatic effect (however my shifts are sporadic and many of these patients have a prolonged ICU stay, certainly may be a benefit just not noticed by me).

It intuitively makes sense as using higher doses or additional agents with different mechanism of actions likely will increase diuresis.  

In some patients we avoid daimox.  Some of our patients are chronic retainers and the loss of their bicarb from the acetazolamide may worsen their chronic acidemia leading to increase their  tachypnea/dyspnea (when off invasive or non-invasive positive pressure) and because of either their obstructive or restrictive lung disease may not be able to adequately compensate putting them at higher risk of failed extubation or trial off BIPAP. 
 

 

 

[MediMike]

More likely to use metolazone or chlorothiazide unless their bicarb is skyrocketing with the loop diuretics.  This trial was interesting, the scoring system they use for their end point is pretty subjective (edema, intervenable effusion/ascites) and when you look at the total amount of difference in UOP its...500mL.  I struggle to believe that half a liter of urine makes that much of a difference, that's like 2 juice boxes.  Maybe 3. 

Also anyone who received a "big" dose of lasix prior to enrollment was excluded, as was anyone on an SGLT2 inhibitor which is becoming much much much more common after trials have shown such great success in these patient populations. 

Long story short I don't know that I'd hit it up as a first line approach by any means.

[EMEDPA]

Thank you both. Sounds like it's not ready for prime time.

[MediMike]

17 hours ago, EMEDPA said:

Thank you both. Sounds like it's not ready for prime time.

Or if it is probably not something you’d need to worry about unless you’re stuck holding onto someone for long enough to have escalated your furosemide dosing a couple times, seen it fail and need additional oomph.

I imagine if you pounded someone with this right out the gate and they were a Lasix responder you may turn them into a prune!

[EMEDPA]

10 minutes ago, MediMike said:

Or if it is probably not something you’d need to worry about unless you’re stuck holding onto someone for long enough to have escalated your furosemide dosing a couple times, seen it fail and need additional oomph.

I imagine if you pounded someone with this right out the gate and they were a Lasix responder you may turn them into a prune!

I started a lasix drip on someone the other day at the request of cardiology at 10 mg/hr after they had failed outpt tx at 80 mg TID.....

[MediMike]

1 hour ago, EMEDPA said:

I started a lasix drip on someone the other day at the request of cardiology at 10 mg/hr after they had failed outpt tx at 80 mg TID.....

That's a weird thing to be asking the ED to do.  It's also unusual to hop straight to a drip because grandma may have forgotten her pills.  The IV bioavailability is about 2x that of PO, giving them a slug of 80 IVP may have gotten them to threshold and started diuresing.  With that said, despite the DOSE trial, I prefer an infusion (inpatient) due to the ability to titrate.