Clinical Briefs
January 15, 2018
Diuretic Use in Heart Failure
SOURCE: Ellison DH, Felker GM. Diuretic treatment in heart failure. N Engl J Med 2017;337:1964-1975.
Diuretics are employed in heart failure for symptom control, but they are not disease-modifying; that is, in contrast to angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, beta-blockers, aldosterone antagonists, hydralazine/isosorbide, and valsartan/sacubitril, each of which has demonstrated meaningful reductions in mortality in heart failure clinical trials, diuretics are employed solely for improved patient quality of life. Perhaps that helps explain why there is remarkably less clinical trial data specifically focused on diuretic therapies for heart failure.
Two areas in which knowledge about best diuretic use is particularly important are acute decompensated heart failure and the scenario of diuretic resistance. For patients with acute decompensated heart failure, a trial comparing twice-daily furosemide IV boluses vs. continuous infusion (using low-dose and high-dose regimens) did not demonstrate any statistically significant difference for the coprimary endpoint of the patient’s global assessment of symptoms. However, secondary endpoint outcomes, which must be regarded as hypothesis-generating rather than definitive since the primary outcome was not achieved, tended to favor high-dose regimens regarding dyspnea, weight change, and net fluid loss.
For diuretic resistance, the authors endorsed continuous diuretic infusion with stepwise dose increases to achieve a 3-5 liter/day urine volume until euvolemia is achieved. The modest amount of clinical trial data to assist clinicians in choosing doses of diuretics, mode of administration, and target fluid losses suggests that much more information is needed.
Sexual Dysfunction Among Diabetics
SOURCE: Owiredu WKBA, Alidu H, Amidu N, et al. Sexual dysfunction among diabetics and its impact on the SQoL of their partners. Int J Impot Research 2017;29:250-257.
Among diabetic men, the pathophysiologic derangements leading to sexual dysfunction are evident. Neuropathy and vascular disease (microvascular and macrovascular) readily explain the disproportionate incidence of observed sexual dysfunction. Explanations for sexual dysfunction in diabetic women, some of whom also have exhibited a higher incidence of sexual dysfunction than age-matched, non-diabetic comparators, are more difficult to discern.
Of the topics related to sexual health, there is less research on the partner impact of sexual dysfunction. Encouragingly, interventions that restore erectile capacity in men (e.g., phosphodiesterase type 5 inhibitors, intracavernosal injection therapy, and vacuum constriction devices) have been associated with corresponding improvements in partner quality of life, albeit not without occasional partner reports of unwelcome improvements in erectile capacity, sometimes labeled “Viagravation.”
In a review of diabetic men (n = 130) and diabetic women (n = 116), evaluations of sexual quality of life in both genders was meaningfully affected by partner sexual dysfunction. Perhaps not surprisingly, age and duration of diabetes were the strongest predictors of sexual dysfunction in diabetic men. The authors opined that insufficient attention has been given to the presence and effect of sexual dysfunction on the quality of life of patients and their partners.
When Gastrointestinal Complaints Are Not Prominent
SOURCE: Paez MA, Gramelspacher AM, Sinacore J, et al. Delay in diagnosis of celiac disease in patients without gastrointestinal complaints. Am J Med 2017:130:1318-1323.
Most clinicians think of celiac disease as primarily a gastrointestinal disorder. Hence, when patients present with typical symptoms (e.g., persistent non-acute abdominal pain, diarrhea) not explained by other disorders, identification of celiac disease by screening for anti-transglutaminase antibodies usually follows. But what about when the gastrointestinal symptom profile of celiac disease is not a prominent part of the picture? Manifestations of celiac disease can be as far reaching as anemia, osteoporosis, abnormal thyroid function tests, and abnormal liver function tests, none of which may produce an immediate prompt to consider celiac disease as the etiology.
Paez et al reviewed data on patients with biopsy-proven celiac disease (n = 101) treated at the Loyola University Medical Center. Patients who presented with gastrointestinal symptoms exhibited a median time to diagnosis of 2.3 months, compared to 42 months for those without gastrointestinal symptoms. While celiac disease certainly is not the most common cause of anemia, osteoporosis, abnormal liver function tests, or abnormal thyroid function tests, these results suggest that clinicians should think of celiac disease earlier in the differential diagnosis process, since the aforementioned consequences are largely remediable through appropriate dietary restrictions.
In this section: using diuretics in heart failure patients; sexual dysfunction in patients with diabetes; and treating subtle gastrointestinal symptoms.
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