The Pharm So Hard Emergency Medicine & Hospital Pharmacy Podcast Episode 126. Part 2 – Loop There It Is! Navigating Diuretics, Resistance, and Heart Failure Therapies
Oct 10, 2025
Dr. Cait Kulig, a cardiology clinician-educator specializing in heart failure management, returns to delve into diuretics and resistance strategies. She highlights the adverse effects of diuresis, including electrolyte imbalances and ototoxicity. Cait discusses innovative solutions like SGLT2s and inotropes, comparing critical options like milrinone and dobutamine. She emphasizes the importance of guideline-directed therapy for HFrEF and HFpEF and shares tips for optimizing treatment during inpatient care, ensuring safe and effective diuresis throughout.
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Prioritize Electrolytes And Treat Contraction Alkalosis
- Monitor electrolytes closely during high-dose loop diuresis and keep potassium >4 mEq/L when possible.
- If contraction alkalosis develops consider acetazolamide 500 mg daily as a tolerated option.
Avoid Huge Boluses To Reduce Ototoxicity Risk
- Avoid very large IV bolus loop doses that raise ototoxicity risk; consider continuous infusion for very high total daily needs.
- Use bioavailability tables from the heart failure guidelines when switching agents during shortages.
Use Multiple Measures To Judge Volume Status
- Assess volume status by integrating urine output, weight change, vital signs and POCUS rather than relying solely on net I's and O's.
- Watch for intravascular depletion despite peripheral edema and slow diuresis if creatinine rises.