Diuretics

For a heart failure patient, fluid congestion may be any or all of the following:

1. Peripheral oedema – build-up of fluid from the feet upwards. The patient may notice that their shoes are tighter, there are marks on the legs by the top of the socks, there is general swelling/tightness of the skin and/or pitting oedema (leaving a thumbprint after pressing)
2. Abdominal bloating – with discomfort, loss of appetite and symptoms of breathlessness when bending over (e.g. tying shoelaces, gardening)
3. Pulmonary oedema (fluid on the lungs) with increasing symptoms of shortness of breath, cough, difficulty lying flat in bed or waking due to breathlessness, sleeping with extra pillows or more propped up in the bed, or even sleeping in a chair.

The aim is to gradually remove the accumulated fluid – no more than 1-2kg/day – as more rapid diuresis can lead to acute kidney injury (AKI). It is helpful if the patient can self-monitor by both reporting on symptoms and by measuring their weight each morning. The rationale for measuring weight is to assess change in congestion with the weight decreasing as fluid is removed or, conversely, still increasing if treatment is not effective. 

A pharmacist explaining to the patient that they are not, in this instance, interested in their weight per se often relieves anxiety over recording and reporting the weight. In some cases, sensitive questioning regarding adherence may be required as patients often cite diuretic use as disruptive to their daily schedule and may omit doses that are ‘inconvenient’, leading to treatment failure.