Pharmacologic Algorithm for Diuresis in CHF

Low Sodium diet Achieve dry

Patient volume 2 Liter Fluid Restriction
overloaded (Sig. PND,
weight or Yes 1,2
Loop Diuretic improving Monitor
Orthopnea, Edema) (e.g.,Furosemide 40mg ) symptoms,
volume status

No

No Lasix daily
Double the dose dose >
3
320mg?

Yes

Achieve Yes 1,2

Monitor
Goal?

HCTZ 25mg No
with
Yes CrCl
Furosemide > Add Thiazide-like
4
40ml/min Diuretic

No 1. Monitoring Parameters:
*Weights: initially 1-2lbs weight loss per day until “ideal” weight
Achieve Dry weight Metolazone 5mg achieved
Yes or improving with Furosemide
4 *Volume depletion
symptoms, volume -Hypotension
status -Dizziness
-Decreased urine output
1,2
Monitor -Increased BUN (BUN/Cr > 20)
No *Electrolytes
+ +
-Supplement K if <3.5 mg/dL in patient not on Digoxin and K <
4.0mg/dL if patient on Digoxin
2. If patient symptoms are controlled during day, but worse at night,
may need to administer diuretic regimen in evening or more
Double HCTZ frequently as needed
SCr <2.5 mg/dl Yes Dose 3. When Furosemide dose is >80-120 mg/day, use BID dosing
Or +
4. May require increase in monitoring and tighter control of K , Mg
2+

CrCL > 40
ml/min

No
Achieve dry
If on HCTZ switch to Consider admitting patient if
Metolazone 5mg. If on
weight or No
improving not already in hospital for IV
Metolazone double the dose. symptoms, Furosemide
volume status

Yes
1,2
Monitor