• Also read: diuretics.
• In case of outpatient treatment, a clinical re-evaluation must always be carried out after 2 or 3 days, including checking the renal function and the ionogram (sodium and potassium) and adjusting the therapy depending on the evolution.
• In the event of a new clinical diagnosis of cardiac decompensation and fluid retention, without the need for hospitalization, it is best to start already the following therapy before the consultation with the cardiologist:
  • A loop diuretic, for example furosemide 40 mg or bumetanide 1 mg per day.
  • An MRA: spironolactone 25 mg per day (if GFR > 30 ml/min and potassium < 5 mmol/l).
  • A low dose of an ACE inhibitor if the blood pressure is > 120/80 mmHg.
  • Do not start a beta-blocker as long as there are signs of cardiac decompensation.

• If the patient is already taking chronic treatment with a loop diuretic:
  • Double the daily dose, possibly in 2 doses (first dose at 8 a.m., second dose around 2 p.m.).
  • Consider switching furosemide to bumetanide due to better peroral bioavailability and better diuretic effect after peroral intake.
    • 40 mg furosemide = 1 mg bumetanide = 20 mg Torasemide.
    • Maximum permitted daily dose of loop diuretics:
      • Bumetanide (Burinex) 2x 5 mg per day
      • Furosemide (Lasix) = 600 mg per day
      • Torasemide (Torrem) = 200 mg per day
      • If necessary, 1-2x the home dose of loop diuretics can be administered intravenously or intramuscularly for 1 or 2 days (if hospitalization is no longer desired).
• Start an MRA, spironolactone (if the patient is not already taking it).
• Start an SGLT2 inhibitor (if the patient is not already taking it) if GFR > 20-25 ml/min and if the patient does not have type I diabetes mellitus. The request for reimbursement must be made via the cardiologist.
• If there is insufficient beneficial effect after increasing the loop diuretic or if the patient is already taking a high daily dose of a loop diuretic (for example bumetanide 5 mg per day or higher), the following options are available (also read: diuretic resistance) :
• • Hospitalization for intravenous therapy and ultrafiltration if necessary.
  • Association of another diuretic:
    • Thiazide diuretic (e.g. chlorthalidone (Hygroton) 50 mg 0.5 or 1 tablet once per day). It is preferable to consult with the (treating) cardiologist. CAUTION: Association of a thiazide diuretic can suddenly increase diuresis significantly and increases the risk of hyponatremia, hypokalemia and deterioration of renal function.
    • Acetazolamide (Diamox).

Usually it is best to continue unchanged as much as possible.

In certain circumstances it may be necessary to temporarily stop the following treatments or halve the dose. After stabilization, an attempt should be made as soon as possible to titrate the dose back to the target dose or the maximum tolerated dose. These circumstances are:

• Hypotension
• Bradycardia
• Renal insufficiency
• Hyperkalemia