Lasix vs. Bumex

[cbrons]

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[Animalcules]

Are you asking if diuretics cause gut edema?


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[sozme]

Are you asking if diuretics cause gut edema?


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key word is less

Is it true that Bumex causes less bowel edema? That is the reason I was given. Didn't even think that was really all that common.

 

[Animalcules]

key word is less

Sorry, what's going on here? Anybody willing to explain their thought process in more detail or add some mechanism?

 

[chessknt]

Diuretics don't cause bowel edema, they improve it via diuresis. Their bioavailability is theoretically lower in highly edematous states due to bowel wall edema.

 

[dozitgetchahi]

Diuretics don't cause bowel edema, they improve it via diuresis. Their bioavailability is theoretically lower in highly edematous states due to bowel wall edema.

Yes - the point is that torsemide and bumetanide (Bumex for the uninitiated) have higher PO bioavailability vs furosemide when the pt is volume overloaded with likely bowel edema - which actually translated into fewer hospitalizations for CHF exacerbations (don't remember the exact paper but it was published from researchers at my residency program).

 

[gutonc]

Yes - the point is that torsemide and bumetanide (Bumex for the uninitiated) have higher PO bioavailability vs furosemide when the pt is volume overloaded with likely bowel edema.

Yeah...the OP clearly misunderstood the teaching point (or was taught very wrong) in this scenario.

Torsemide and bumetanide have better oral bioavalabilty than Lasix. Which is a big deal if there's gut edema.

But honestly, if you're at the gut edema stage and still worried about oral bioavalabilty, you're doing it wrong.

 

[dozitgetchahi]

Yeah, agreed.

 

[jdh71]

If I'm not giving it IV you have been good enough for the floor for awhile and need to gtfo of my unit.

 

[Instatewaiter]

Ethacrynic acid is my loop of choice. Bioavailability? What's that?

 

[Raryn]

Ethacrynic acid is my loop of choice. Bioavailability? What's that?

Can't hear your question, too much ethacrynic acid.

 

[dozitgetchahi]

Yeah...the OP clearly misunderstood the teaching point (or was taught very wrong) in this scenario.

Torsemide and bumetanide have better oral bioavalabilty than Lasix. Which is a big deal if there's gut edema.

But honestly, if you're at the gut edema stage and still worried about oral bioavalabilty, you're doing it wrong.

Asterisk: per the researchers at my old institution who wrote some of these papers, it's theorized that a lot of people with >moderate CHF have a degree of bowel edema 24/7, and supposedly placing these people on PO torsemide helps reduce the risk of exacerbations because of the better PO bioavailability. Their study actually demonstrated an overall cost savings, reduced number of days in the hospital, etc etc for these types of CHFers on PO torsemide vs those on PO Lasix.

Not sure if this is 100% agreed upon, however, as I remember seeing some later literature that implied that Lasix PO bioavailability was better than initially suspected and that there was basically no significant cost savings by using torsemide.

 

[Raryn]

Asterisk: per the researchers at my old institution who wrote some of these papers, it's theorized that a lot of people with >moderate CHF have a degree of bowel edema 24/7, and supposedly placing these people on PO torsemide helps reduce the risk of exacerbations because of the better PO bioavailability. Their study actually demonstrated an overall cost savings, reduced number of days in the hospital, etc etc for these types of CHFers on PO torsemide vs those on PO Lasix.

Not sure if this is 100% agreed upon, however, as I remember seeing some later literature that implied that Lasix PO bioavailability was better than initially suspected and that there was basically no significant cost savings by using torsemide.

Couldn't you solve the same chronic issue by just increasing the dose of lasix?

In the acute setting, I absolutely get difficulties with bowel edema (... and that's why I use IV diuretics) but chronically, if bioavailability is the concern, you can just increase the dose, no?

 

[Instatewaiter]

Asterisk: per the researchers at my old institution who wrote some of these papers, it's theorized that a lot of people with >moderate CHF have a degree of bowel edema 24/7, and supposedly placing these people on PO torsemide helps reduce the risk of exacerbations because of the better PO bioavailability. Their study actually demonstrated an overall cost savings, reduced number of days in the hospital, etc etc for these types of CHFers on PO torsemide vs those on PO Lasix.
.

I Agree. We almost universally use torsemide in our advanced heart failure patients because we find that we have fewer volume issues than with lasix.

Couldn't you solve the same chronic issue by just increasing the dose of lasix?

In the acute setting, I absolutely get difficulties with bowel edema (... and that's why I use IV diuretics) but chronically, if bioavailability is the concern, you can just increase the dose, no?

The issue is that chronically they will have paroxysms of volume overload. If their gut edema causes them to get into a viscious cycle you will have a higher likelihood of admission. So, it is less about the chronic dose and more the response to volume overload.

 

[theneh]

The PO superiority of torsemide to lasix is something i agree with in theory and seem to appreciate in practice, though less pronounced when compared to bumetanide. Need better RCT for this comparison, or maybe I have not found a good one, honestly, haven't been searching.
With regard to IV bumex vs. lasix... in critically ill patients with edema, hypoalbuminemia, some nephrologists I know speculate that bumex has a smaller Vd (compared to lasix) attributable to enhanced globulin-binding and therefore increased renal tubular secretion and superior diuretic effect. Although it is true that there is enhanced non-albumin protein binding w/ bumex, in an old study the diuretic effect (6 hr urine flow rate, Na, K, excretion) was no different despite comparable doses (this in analbuminemic RATS). What is more interesting, in patients with advanced renal failure, on more than one occasion "equivalent" doses of lasix and bumex (dose ratio of 40:1) actually yielded greater diuretic effect in the lasix recipients, so much so that in advanced renal failure patients, the equivalent lasix:bumex dose ratio approached 20:1 (Voelker et all, KI 1987- OLD). The reason for this is due to untouched hepatic metabolism of bumex while non-renal metabolism of furosemide is decreased by close to 50% ( the exact mechanism of decreased metabolism I am not aware of). This translates to increased renal tubular concentration of furosemide compared to bumex , hence, enhanced diuretic effect. Seems like intravenously, there is no good reason to choose bumex over lasix and in fact, lasix is likely more efficacious in patients with renal failure (maybe twice as effective per old KI article). These differences become less relevant as the diuretic-resistance forces increase and concomitant use of other diuretic options should be considered.