Disposition and response to bumetanide and furosemide

Heart Failure With Reduced Ejection Fraction: A Review

IMPORTANCE

Worldwide, the burden of heart failure has increased to an estimated 23 million people, and approximately 50% of cases are HF with reduced ejection fraction (HFrEF).

OBSERVATIONS

Heart failure is a clinical syndrome characterized by dyspnea or exertional limitation due to impairment of ventricular filling or ejection of blood or both. HFrEF occurs when the left ventricular ejection fraction (LVEF) is 40% or less and is accompanied by progressive left ventricular dilatation and adverse cardiac remodeling. Assessment for heart failure begins with obtaining a medical history and physical examination. Also central to diagnosis are elevated natriuretic peptides above age- and context-specific thresholds and identification of left ventricular systolic dysfunction with LVEF of 40% or less as measured by echocardiography. Treatment strategies include the use of diuretics to relieve symptoms and application of an expanding armamentarium of disease-modifying drug and device therapies. Unless there are specific contraindications, patients with HFrEF should be treated with a β-blocker and one of an angiotensin receptor-neprilysin inhibitor, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker as foundational therapy, with addition of a mineralocorticoid receptor antagonist in patients with persistent symptoms. Ivabradine and hydralazine/isosorbide dinitrate also have a role in the care of certain patients with HFrEF. More recently, sodium-glucose cotransporter 2 (SGLT2) inhibitors have further improved disease outcomes, significantly reducing cardiovascular and all-cause mortality irrespective of diabetes status, and vericiguat, a soluble guanylate cyclase stimulator, reduces heart failure hospitalization in high-risk patients with HFrEF. Device therapies may be beneficial in specific subpopulations, such as cardiac resynchronization therapy in patients with interventricular dyssynchrony, transcatheter mitral valve repair in patients with severe secondary mitral regurgitation, and implantable cardiac defibrillators in patients with more severe left ventricular dysfunction particularly of ischemic etiology.

CONCLUSIONS AND RELEVANCE

HFrEF is a major public health concern with substantial morbidity and mortality. The management of HFrEF has seen significant scientific breakthrough in recent decades, and the ability to alter the natural history of the disease has never been better. Recent developments include SGLT2 inhibitors, vericiguat, and transcatheter mitral valve repair, all of which incrementally improve prognosis beyond foundational neurohormonal therapies. Disease morbidity and mortality remain high, with a 5-year survival rate of 25% after hospitalization for HFrEF.

Molecular regulation of NKCC2 in blood pressure control and hypertension

PURPOSE OF REVIEW

The apical Na/K/2Cl cotransporter (NKCC2) mediates NaCl reabsorption by the thick ascending limb, contributing to maintenance of blood pressure (BP). Despite effective NKCC2 inhibition by loop diuretics, these agents are not viable for long-term management of BP due to side effects. Novel molecular mechanisms that control NKCC2 activity reveal an increasingly complex picture with interacting layers of NKCC2 regulation. Here, we review the latest developments that shine new light on NKCC2-mediated control of BP and potential new long-term therapies to treat hypertension.

RECENT FINDINGS

Emerging molecular NKCC2 regulators, often binding partners, reveal a complex overlay of interacting mechanisms aimed at fine tuning NKCC2 activity. Different factors achieve this by shifting the balance between trafficking steps like exocytosis, endocytosis, recycling and protein turnover, or by balancing phosphorylation vs. dephosphorylation. Further molecular details are also emerging on previously known pathways of NKCC2 regulation, and recent in-vivo data continues to place NKCC2 regulation at the center of BP control.

SUMMARY

Several layers of emerging molecular mechanisms that control NKCC2 activity may operate simultaneously, but they can also be controlled independently. This provides an opportunity to identify new pharmacological targets to fine-tune NKCC2 activity for BP management.

Angiotensin II decreases nitric oxide synthase 3 expression via nitric oxide and superoxide in the thick ascending limb

NO produced by NO synthase type 3 (NOS3) in medullary thick ascending limbs (mTHALs) inhibits Cl(-) reabsorption. Acutely, angiotensin II stimulates thick ascending limb NO production. In endothelial cells, NO inhibits NOS3 expression. Therefore, we hypothesized that angiotensin II decreases NOS3 expression via NO in mTHALs. After 24 hours, 10 and 100 nmol/L of angiotensin II decreased NOS3 expression by 23+/-9% (n=6; P<0.05) and 50+/-5% (n=7; P<0.001), respectively, in primary cultures of rat mTHALs. NO synthase inhibition by 4 mmol/L of N(G)-nitro-L-arginine methyl ester hydrochloride prevented angiotensin II from decreasing NOS3 expression (Delta=-5+/-8%; n=5). In the presence of N(G)-nitro-L-arginine methyl ester hydrochloride, the addition of exogenous NO (1 micromol/L spermine NONOate) restored the angiotensin II-induced decreases in NOS3 expression (-22+/-6%; n=7; P<0.013). In addition, NO scavenging with 10 micromol/L of carboxy-PTIO abolished the effect of angiotensin II in NOS3 expression (Delta=-1+/-8% versus carboxy-PTIO alone; n=6). Angiotensin II increases superoxide, and superoxide scavenges NO. Thus, we tested whether scavenging superoxide enhances the angiotensin II-induced reduction in NOS3 expression. Surprisingly, treatment with 100 micromol/L of Tempol, a superoxide dismutase mimetic, blocked the angiotensin II-induced decrease in NOS3 expression (Delta=-3+/-7%; n=6). This effect was not because of increased hydrogen peroxide. We concluded that angiotensin II-induced decreases in NOS3 expression in mTHALs require both NO and superoxide. Decreased NOS3 expression by angiotensin II in mTHALs could contribute to increased salt retention observed in angiotensin II-induced hypertension.

New insights into diuretic use in patients with chronic renal disease

Patients with chronic renal insufficiency (CRI) or the nephrotic syndrome frequently manifest diuretic resistance. Factors limiting diuretic responsiveness in patients with CRI may include a reduced basal level of fractional Na(+) reabsorption that places an upper limit on diuretic response, and enhanced NaCl reabsorption in downstream segments, combined with a reduced delivery of diuretic to the kidney. Diuretics are secreted by the recently characterized organic anion transporters (OATs), which are expressed in proximal tubule cells. Secretion may be inhibited by retained organic anions, urate, or acidosis. These limitations necessitate an increased diuretic dosage, up to a defined ceiling level, and consideration of the use of a nonrenally metabolized loop diuretic rather than furosemide. Diuretic responsiveness in patients with the nephrotic syndrome is limited by avid Na(+) reabsorption by the terminal nephron. Experimental studies have shown that a reduced serum albumin concentration can increase the volume of distribution of loop diuretics, reduce their tubular secretion, and enhance the inactivation of furosemide within the kidney by glucuronidization. Binding of loop diuretics can curtail their action in the loop of Henle. Recent clinical investigations have challenged the importance of some of these mechanisms that were identified in animal models. Strategies to improve loop diuretic responsiveness include increasing diuretic dosage, concurrent use of a thiazide diuretic to inhibit downstream NaCl reabsorption and attempts to maximally reduce albumin excretion. Strategies to limit albumin excretion include the use of an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker and appropriate limitation of protein intake. These measures are more logical, effective, and less expensive than infusion of albumin solutions.

Effect of short-term treatment with bumetanide, quinapril and low-sodium diet on dogs with moderate congestive heart failure

OBJECTIVE

To evaluate the effect of bumetanide, quinapril and a low-sodium diet on clinical response tolerance and side-effects on dogs with moderate congestive heart failure.

DESIGN

A prospective clinical study, using 32 client-owned dogs with naturally occurring disease.

PROCEDURE

Thirty-two dogs diagnosed with congestive heart failure (International Small Animal Cardiac Health Council stage II) due to mitral valve disease were included. During 4 weeks, patients received 0.5 mg/kg quinapril (Ectren, Menarini), 0.1 mg/kg bumetanide (Fordiuran, Boehringer Ingelheim) and a low sodium diet (CNM-CV, Purina) was fed. All dogs were examined weekly and results were treated statistically.

RESULTS

The treatment was safe, effective and well-tolerated and no major side-effects were observed. There were no significant changes in measured haematological and biochemical variables, including serum electrolyte concentrations and urinary fractional excretion of electrolytes.

CONCLUSION

This study suggests that the combined treatment with bumetanide, quinapril and low-sodium diet for controlling moderate CHF due to mitral insufficiency in dogs is simple, easy-to-administer and effective in controlling clinical signs and prompting improvement even after short-term treatment.

Reversing oliguria in critically ill patients

Oliguria is a common occurrence in the ICU setting. In patients with preserved renal function, fluid challenges or low doses of diuretics are generally successful. In patients with oliguric renal failure, it is still essential to ensure adequate intravascular fluid volume, especially in critically ill patients. Loop diuretics remain the mainstay of treatment. When diuretic resistance is encountered, physicians should consider further optimization of hemodynamics, alternative loop diuretics, and combined drug therapy. In some cases, continuous renal replacement therapy can be very effective. Yet, while these interventions can help reduce the morbidity of severe volume overload, they have not been shown to improve mortality rates.

Pharmacokinetics and pharmacodynamics in the critically ill patient

1. Until recently, when drugs were used in critically ill patients they were expected to behave in the same way as in less seriously ill patients. Now the unpredictability of even the most reliable drugs has been recognized. With this there is an awareness of the adverse effects drugs may have on organs other than the ones the drug was intended to act on. In patients with multiorgan dysfunction, poly-pharmacy is usually needed. The drugs may not only interfere with the action of each other at the receptor and enzyme level, but may also change protein binding and elimination. All these effects may be unimportant in less seriously ill patients, but may affect outcome in the critically ill. A high degree of awareness and suspicion of unknown drug-induced adverse reaction is needed by clinicians and pharmacologists alike.

Bumetanide/amiloride ('Burinex A'): a new combined preparation for the control of patients with congestive cardiac failure

Two hundred and thirty-three patients (66 males and 167 females), aged 24 to 92 years, with congestive cardiac failure were entered into a long-term study to evaluate the efficacy and tolerability of treatment with a fixed dose combination tablet containing 1 mg bumetanide and 5 mg amiloride. One hundred and fifty-five patients were treated for 52 weeks. The daily dosages were 1 tablet (113 patients), 2 tablets (35 patients), 3 or 4 tablets (7 patients). Treatment was associated with a marked reduction in the prevalence of ankle oedema, dyspnoea and pulmonary crepitations, and with statistically significant decreases in body weight, pulse rate and calf measurement. Mean serum potassium showed a small but statistically significant increase, but serious hyperkalaemia was not encountered. Although serum sodium decreased, serious hyponatraemia did not occur. No clinically significant effects on hepatic, renal or haemopoietic function were observed. Minor adverse effects, most of which resolved spontaneously, were reported by 60 patients. Only 14 (6.0%) patients ceased treatment because of adverse effects.

Comparison of loop diuretics in patients with chronic renal insufficiency

Furosemide and bumetanide share a number of characteristics including reduced natriuretic effects in azotemic patients. It has been presumed that this condition affects each drug equally. Previous studies, however, suggest dissimilar pathways of delivery to their sites of action. Though not rigorously tested, this potential disparity might cause them to differ when used in azotemia. We, therefore, assessed the pharmacokinetic and pharmacodynamic characteristics of intravenously administered furosemide and bumetanide in ten adult patients with stable, chronic renal insufficiency (mean creatinine clearance = 14.1 +/- 2.0 ml/min/1.73 m2) in a randomized, cross-over study during controlled sodium intake. Our goals were to assess differences in diuretic effectiveness and in so doing to determine the dose required to produce a maximal response. The mean diuretic doses of 172 and 4.3 mg for furosemide and bumetanide, respectively (ratio = 40:1) were sufficient to produce a maximum response. Despite similarities in maximal fractional excretion of sodium (18.2 +/- 2.6% with furosemide vs. 19.4 +/- 4.5% with bumetanide, P = 0.687) demonstrating an equal tubular responsiveness to both drugs, overall response as quantified by cumulative natriuresis in the initial eight hour period was 52% greater with furosemide (108 +/- 17 vs. 71 +/- 7 mEq; P = 0.042). The difference in total excreted sodium was accounted for by a preserved nonrenal clearance of bumetanide (113 +/- 12 compared to 53 +/- 5 ml/min for furosemide, P = 0.001) which resulted in relatively less bumetanide in serum available to be delivered into the urine.(ABSTRACT TRUNCATED AT 250 WORDS)

Intravenous bumetanide attenuates the rise in plasma vasopressin concentrations during major surgical operations

During a study in seven patients on the endocrine response to major surgical procedures under general anaesthesia an incidental finding was that the administration of intravenous bumetanide prior to surgical stimulation led to reduced concentrations of plasma vasopressin (AVP) when compared with a control group of patients.