Thiazide vs. Loop diuretics - Heart Failure

[Confusant]

What's the big issue with choosing one from another in the tx of heart failure?

Thanks!

(Yes I am googling for more information as we speak, but so far no information yielded)

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[rx2010]

Loop diuretics are usually used over thiazides in HF since it's more potent in reducing the edema in HF than thiazides. Thiazides are usually added on top of the loops when the loops aren't helping much in reducing the edema.

 

[J ROD]

Loops are more potent, but have no mortality benefit. Thiazides are not that great at getting off the edema...

 

[J ROD]

What's the big issue with choosing one from another in the tx of heart failure?

Thanks!

(Yes I am googling for more information as we speak, but so far no information yielded)

I will prepare you for rotations.....go find the guidelines and look it up, lol!!

 

[BMBiology]

Loops are more potent, but have no mortality benefit. Thiazides are not that great at getting off the edema...

Thiazides do not increase mortality.

 

[Glycerin]

Thiazides do not increase mortality.

I didn't read that as the poster implying that thiazides have affect on mortality, but just stating that loops have no effect on mortality.

 

[rx2010]

Thiazides do not increase mortality.

I think he meant that loops have no effect/benefit in decreasing mortality.

 

[J ROD]

I didn't read that as the poster implying that thiazides have affect on mortality, but just stating that loops have no effect on mortality.

Right on!!

 

[J ROD]

Thiazides do not increase mortality.

The period concludes a thought. See where the period is?


Loops are more potent, but have no mortality benefit. Thiazides are not that great at getting off the edema...


It is before thiazides so I was referencing loops...thiazides have no mortality benefit either....🙂

 

[BMBiology]

The period concludes a thought. See where the period is?

So defensive you are. I was just adding additional info.

 

[aboveliquidice]

Loop diuretics are usually used over thiazides in HF since it's more potent in reducing the edema in HF than thiazides. Thiazides are usually added on top of the loops when the loops aren't helping much in reducing the edema.

HCTZ is #1 choice for HTN unless there is a compelling indication - Which HF is - but your best bang-for-buck comes from an ACE/ARB + Loop.

At what point is HCTZ no longer useful/beneficial? Is it ever removed from therapy (aside from obvious therapy disquals)?

 

[J ROD]

So defensive you are. I was just adding additional info.

Sorry, sounded like you were correcting me!! 🙂

 

[J ROD]

At what point is HCTZ no longer useful/beneficial? Is it ever removed from therapy (aside from obvious therapy disquals)?

If you have a CrCl < 30, then thiazides do not work....

 

[Quiksilver]

HCTZ is #1 choice for HTN unless there is a compelling indication - Which HF is - but your best bang-for-buck comes from an ACE/ARB + Loop.

At what point is HCTZ no longer useful/beneficial? Is it ever removed from therapy (aside from obvious therapy disquals)?

HCTZ should not be used as a stand alone agent. You should be comboing antihypertensives. Also you have to consider the source of the hypertension. Hypertension is usually not a stand alone issue.

 

[KUMoose]

HCTZ should not be used as a stand alone agent. You should be comboing antihypertensives. Also you have to consider the source of the hypertension. Hypertension is usually not a stand alone issue.

So taking a patient that is 145/80 (no underlying additives) you should have them on two meds? Are you sure that's what JNC7 says?

In complex cases I'm not sure there's an obvious take the HCTZ off the table point (aside from obvious disquals). I'm sure JNC8 will change that, from what I've kinda cobbled together HCTZ was the defacto first choie because it was the cheap ubiquitous option. Not because a glut of supportive documentation. That being said I'd wager, if I was a betting man, that ACEI will be first line come next year,

 

[J ROD]

HCTZ should not be used as a stand alone agent. You should be comboing antihypertensives. Also you have to consider the source of the hypertension. Hypertension is usually not a stand alone issue.

JNC7 says that HCTZ is the first line agent to be used and then other therapies added on. ACE, CCB, etc.

This is not for compelling reasons just plain HTN.

With that said, you usually add other agents on like ACEs for renal protection because alot of folks have diabetes. Also, HCTZ is not the best agent and does not always control HTN. But, I have seen it work alone for a few folks that had no other problems and slightly HTN.

 

[Quiksilver]

So taking a patient that is 145/80 (no underlying additives) you should have them on two meds? Are you sure that's what JNC7 says?

In complex cases I'm not sure there's an obvious take the HCTZ off the table point (aside from obvious disquals). I'm sure JNC8 will change that, from what I've kinda cobbled together HCTZ was the defacto first choie because it was the cheap ubiquitous option. Not because a glut of supportive documentation. That being said I'd wager, if I was a betting man, that ACEI will be first line come next year,

Thanks for reading in between the lines. There often is an underlying cause to the HTN. If its not, monotherapy may be indicated however, monotherapy is often not enough to reach goal. Especially with diuretics, pseudotollerance develops as a result of the body's defense mechanisms. SNS, RAAS and other controls will resist the change in blood pressure. You need another agent to counter that.

Before you get a chub over JNC7, endpoints are the same, the 1st line agents had very similar results, only reason why HCTZ is favored is cost. Combination therapy is where its at. I would ask you how many patients do you see on just 1 antihypertensive?

I could regurgitate guidelines all day too. To think about guidelines is another thing.

JNC7 says that HCTZ is the first line agent to be used and then other therapies added on. ACE, CCB, etc.

This is not for compelling reasons just plain HTN.

With that said, you usually add other agents on like ACEs for renal protection because alot of folks have diabetes. Also, HCTZ is not the best agent and does not always control HTN. But, I have seen it work alone for a few folks that had no other problems and slightly HTN.

So your saying that HCTZ is first line but doesn't always control HTN?

 

[J ROD]

So your saying that HCTZ is first line but doesn't always control HTN?

Correct!! That's why there are alot of combo products with HCTZ.....

Also, HCTZ should be started at 25mg because the 12.5mg is crap as a single agent. I could piss more using a beer, lol!!! 😀

 

[KUMoose]

So let's be clear you're advocating elimination of monotherapy or just HCTZ monotherapy?

Because yes I've seen it work in combination +/- diet and exercise and I've seen it fail +/- diet and exercise. I've also seen patients fail and succeed on other monotherapies. I believe the ultimate goal over the guidelines that apparently make me chub is that treating HTN isn't a z0mg crisis but rather a methodical process that starts with personal changes in addition to the possibility of adding pharmacological options.

 

[spacecowgirl]

treating HTN isn't a z0mg crisis but rather a methodical process that starts with personal changes in addition to the possibility of adding pharmacological options.

I disagree. Nice in theory, doesn't work in reality. I wish people would adopt a DASH diet and cut down on sodium, but the truth is that they will have a stroke before they give up their salt shaker and smokes.

In practice, I usually skip right over lifestyle modifications because that's real life. I wish every medication was administered SQ at least BID because that seems to be the only time I have been able to motivate someone to make lifestyle changes - threatening with insulin.

 

[meister]

I believe the ultimate goal over the guidelines that apparently make me chub is that treating HTN isn't a z0mg crisis but rather a methodical process that starts with personal changes in addition to the possibility of adding pharmacological options.

The ultimate goal is to lower morbidity and mortality, and initiating HCTZ therapy has been shown to do just such a thing. If someone doesn't get shocked at their high BP and their physician feeling it necessary to prescribe medication to help control it, then they most likely aren't going to bother decreasing the amount of sodium they eat or exercising more no matter how many ways their doctor tells them they are slowly killing themselves. Just like most patients over 30 who smoke a pack a day won't stop ever, no matter how many times their doctor may bring it up.

Regardless, there's not much harm in starting a patient on HCTZ 25mg QD as well as counseling the patient on lifestyle and diet modifications. If the patient's BP is well under control in a few months then you could easily take away the medication and see what happens.

 

[J ROD]

So let's be clear you're advocating elimination of monotherapy or just HCTZ monotherapy?

No, you start with monotherapy. Most often times with HCTZ. If that is not cutting it, then add an additional agent like a CCB or ACE.

You dont want to drop someone's BP alot (what is the risk?) usually unless they are having a crisis or their BP is really high (we hit them with some hydralazine).

I prefer gradual but if they are showing S/S then I try to bring it down fast but not too fast. 🙂

 

[spacecowgirl]

I prefer gradual but if they are showing S/S then I try to bring it down fast but not too fast. 🙂

Again, nice in theory but gradual will probably mean another 2-3 years of suboptimal HTN treatment. You see a patient, you diagnose them with HTN you say "hey try these LSMs and see me in 6 months". They come back in 18 months. Still high. You give them whatever first line agent you want, tell them to RTO in 3 months, they come back in 6 or 12 and low and behold, it's still not at goal. Or worse they are in the ER for a hypertensive crisis or worse. You've just lost a couple of years in there of having good BP control.

Do not underestimate the human (patient) failure factor here. I'm not saying slam a new diagnosis with 2 agents right away, but I am saying watchful waiting works for otitis not diabetes or HTN or lipids.

 

[Quiksilver]

So let's be clear you're advocating elimination of monotherapy or just HCTZ monotherapy?

Because yes I've seen it work in combination +/- diet and exercise and I've seen it fail +/- diet and exercise. I've also seen patients fail and succeed on other monotherapies. I believe the ultimate goal over the guidelines that apparently make me chub is that treating HTN isn't a z0mg crisis but rather a methodical process that starts with personal changes in addition to the possibility of adding pharmacological options.

More times then not people fail monotherapy, whatever that may be, even with ace-i. Its a fact, the body has compensatory mechanisms that will ultimately result in failure. HTN is not a crisis either, but the risks of hypertension are well noted and documented. It is important to get them to reach their goal as quick as possible. I am sure you know the pathophysiology behind what happens with hypertension.

I am also more apt to start with ACE-I then thiazides. For one, the endpoint result in blood pressure was the same for both classes in the big studies that JNC-7 published. ACE-I are renal protective and cardioprotective, and are used 1st line in patients with diabetes and heart failure. Renal protection occurs with these agents in even normotensive patients and is independent of their blood pressure abilities. The side effect profile is nearly similar and both are well tollerated. except for the acute renal failure which when dosed properly isn't as big as an issue. So yeah thats why i choose them over thiazides.

 

[J ROD]

Again, nice in theory but gradual will probably mean another 2-3 years of suboptimal HTN treatment. You see a patient, you diagnose them with HTN you say "hey try these LSMs and see me in 6 months". They come back in 18 months. Still high. You give them whatever first line agent you want, tell them to RTO in 3 months, they come back in 6 or 12 and low and behold, it's still not at goal. Or worse they are in the ER for a hypertensive crisis or worse. You've just lost a couple of years in there of having good BP control.

Do not underestimate the human (patient) failure factor here. I'm not saying slam a new diagnosis with 2 agents right away, but I am saying watchful waiting works for otitis not diabetes or HTN or lipids.

First, gradual is not "years"....more like months (3)!

More importantly, patients have to take the meds!

Thanks for the lesson!!🙄

 

[spacecowgirl]

First, gradual is not "years"....more like months (3)!

More importantly, patients have to take the meds!

Thanks for the lesson!!🙄

You obviously didn't really understand what I was saying. You assume the patient will come back when you say to come back. They don't. Which is how gradual goes from your intended months to the actuality of years.

Don't roll your eyes at me, grasshopper. Why the rudeness?

 

[spacecowgirl]

If someone doesn't get shocked at their high BP and their physician feeling it necessary to prescribe medication to help control it, then they most likely aren't going to bother decreasing the amount of sodium they eat or exercising more no matter how many ways their doctor tells them they are slowly killing themselves.

Sad but true.

 

[meister]

How can a pharm student be "more apt to start with ACEi"? What makes you think you know better than thousands of research hours that have shown HCTZ + lifestyle changes are the best initial therapy for essential HTN?

Honestly I'm curious. You have any studies at all backing you up? Or are you just in love with ACEis? Would anyone disagree with the fact that HCTZ is less harmful than an ACEi?

 

[J ROD]

You obviously didn't really understand what I was saying. You assume the patient will come back when you say to come back. They don't. Which is how gradual goes from your intended months to the actuality of years.

Don't roll your eyes at me, grasshopper. Why the rudeness?

When I said gradually first, I mean bring it down over a month or two. Try something first for a month and then adjust each month, two weeks, whatever. Your examples mentioned like 6 months come back and 3 months each becoming years...I would not bring them back like that. Nice in theory....Hence, the "tude". You assumed my plan of gradual. Your theory laid out is not mine....

I know patients dont come back....OR take their meds. That's why the best plan is the one that is actually followed. I would never bring someone I am working on their BP back in 6 months only once I had them stable and at goal.

Basically, your example of my thoughts on gradual sucked....

I am purely talking plans here....the whole thing with patients not coming back and not taking their meds is something I bitched at them weekly about....I concur with that. That's not what I am getting at. Your plan at coming back at 6 months from the start of therapy I think is not that great....

I still may be young on what I know but I am older than you...😛

 

[spacecowgirl]

guess we'll just have to agree to disagree 😕

I still may be young on what I know but I am older than you...😛

You sure? I'm old 😉

 

[J ROD]

guess we'll just have to agree to disagree 😕



You sure? I'm old 😉

I'm 30...🙁

I was older than several of my teachers...

 

[spacecowgirl]

I'm 30...🙁

I was older than several of my teachers...

Yeaaahhh. You're not older than me. Grasshopper.

 

[J ROD]

Yeaaahhh. You're not older than me. Grasshopper.

Sorry, Ant!!! 😀