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Editorial
Subcutaneous furosemide in
infusion (n=3).5 In a retrospective analy-sis of 43 episodes of decompensation in 32 advanced heart failure patients treated advanced heart failure: has
in hospital, community or hospice set-tings by a palliative care–heart failure clinical practice run ahead of
collaborative, the continuous SC infu-sion of a dose of furosemide empirically based on their last daily oral dose and the evidence base?
uptitrated according to response (dose range 40–250 mg daily) was demonstra- bly effective in relieving congestion, in facilitating early hospital discharge or in the prevention of admission in 26/28 epi- tom relief. However, with the exception Although the objective confi rmation of a reduction in fl uid overload was imprac- gestive heart failure due to left morphone, few drugs have randomised tical in a subset of 15 hospice patients has signifi cantly improved the outlook venous routes of administration. Many oped terminal dyspnoea.
of those diagnosed with this condition drugs are thus used outside their regula-
and many patients now live longer and tory license in terms of clinical indication
more comfortable lives. Comprehensive and mode of delivery. This is acceptable CLINICAL EXPERTISE
heart failure care is largely founded on when the prescriber can demonstrate that
Despite the relative paucity of published the results of robust randomised clinical their practice accords with a consensus evidence as described above, there has trials of drug, device and cardiac surgi- cal interventions which are enshrined as sional experience and opinion. There are the basis of widely implemented clinical also guidelines regarding the use of drugs USA.7 8 This practice has been endorsed in tance of an appropriate discussion of such the palliative care drug formulary (palli- ple of the application of evidence based a management plan with the patient.2 ativedrugs.com), and a series of protocols Over the past decade, the use of SC have been formulated for the symptom- atic care of heart failure patients at the stage heart failure has increased, particu- end of life. While it is accepted practice to their families, and is often complicated larly in the fi eld of palliative care. There is clearly a growing body of professional cation within a clinical protocol, there is bidities common in the typically affected opinion, but is this treatment protocol a risk that this lends authority to such an older population. Heart failure still tends supported by the parallel development of cine has been defi ned as ‘the integration is consistently effective, and fail to pre- care skills should be central to the multi- expertise and patient values’.3 We shall atic assessment of the benefi ts and risks mately fatal illness.1 Their contribution consider the use of SC furosemide for of such clinical management.
is predominantly relevant to those with advanced heart failure in terms of these PATIENT VALUES
of life. Indeed such heart failure patients are increasingly treated by specialist pal- BEST RESEARCH EVIDENCE
liative care teams in hospitals, hospices Furosemide is unlicensed for SC use. dence based medicine is consistent with However, the diuretic effect of this mode heart failure care. Patient perspectives in a randomised placebo controlled trial on improving current management have liative care practice for the continuous of 12 healthy normal volunteers aged highlighted the importance of open sen- 22–56 years (mean 36), when the SC sitive dialogue in establishing a mutu- bolus injection of 20 mg of furosemide ally agreed bespoke care plan to address Department of Cardiology, Heart of England NHS elicited a statistically signifi cant diuretic Foundation Trust, Birmingham, UK; National Clinical Lead, NHS Heart Improvement.
and natriuretic response lasting up to of care across all healthcare settings with 2Department of Health Sciences, Hull York Medical 4 h.4 A subsequent report confi rmed the defi ned responsibilities for informal and School, University of Hull; St Catherine’s Hospice, clinical effectiveness of this route of drug professional carers. There should also be delivery in the treatment of 8 ‘home hos- regular review of goals of care along the Correspondence to Dr James M Beattie,
pice’ advanced heart failure patients aged Department of Cardiology, Heart of England NHS 58–79 years (mean 72) with congestion sation of treatment towards maintaining Foundation Trust, Heartlands Hospital, Bordesley Green East, Birmingham B9 5SS, UK; resistant to oral diuretic therapy. The dose the quality of their remaining life.9 As BMJ Supportive & Palliative Care March 2012 Vol 2 No1 Editorial
of treatment offered earlier in the course the palliative care workshop of the Heart Failure semide would seem to provide a useful, of the illness. The burden of proof of this Association of the European Society of Cardiology.
Eur J Heart Fail 2009;11:433–43.
potentially benefi cial therapy lies with 2. The use of drugs beyond licence in palliative care toms of congestion, while allowing us as clinicians and palliative medicine and pain management. A position statement patients to be cared for and die in their must not baulk from the requirement prepared on behalf of the Association for Palliative place of choice.6 However, it is important to develop a research base justifying its Medicine and the British Pain Society. November that this approach is discussed with the 2005. http://www.britishpainsociety.org/book_usingdrugs_main.pdf (accessed on 4 August 2011).
tunities for study, and research themes 3. Sackett DL, Straus SE, Richardson WS, et al.
ments of informed consent, patient might include (1) identifying the clinical Evidence-based Medicine: How to Practice and choice and joint patient–clinician deci- Teach EBM. Edinburgh: Churchill Livingstone 2000:3.
4. Verma AK, da Silva JH, Kuhl DR. Diuretic effects
of subcutaneous furosemide in human volunteers: Synthesis of the available data and the logistics of drug administration; and a randomized pilot study. Ann Pharmacother observation of evolving clinical practice (3) assessing the benefi ts and burdens 2004;38:544–9.
suggests that the current use of SC furo- 5. Goenaga MA, Millet M, Sánchez E, et al.
semide in the end of life care of advanced Subcutaneous furosemide. Ann Pharmacother heart failure is only at the threshold of viding parenteral loop diuretic therapy 2004;38:1751.
6. Zacharias H, Raw J, Nunn A, et al. Is there a role
compliance with the three prima facie appropriate to a relatively frail advanced for subcutaneous furosemide in the community and principles required of the defi nition of heart failure population across a variety hospice management of end-stage heart failure? evidence based medicine. There are of care settings, but we need to test that Palliat Med 2011;25:658–63.
7. Herndon CM, Fike DS. Continuous subcutaneous
infusion practices of United States hospices. J Pain Competing interests None.
Symptom Manage 2001;22:1027–34.
tional data is derived from small patient 8. Fonzo-Christe C, Vukasovic C, Wasilewski-Rasca
cohorts. Thus, at present, the use of SC Provenance and peer review Not commissioned;
AF, et al. Subcutaneous administration of drugs in the elderly: survey of practice and systematic literature review. Palliat Med 2005;19:208–19.
9. Low J, Pattenden J, Candy B, et al. Palliative
espoused this form of treatment, the Accepted 9 November 2011 care in advanced heart failure: an international genie may be out of the bottle, but ques- BMJ Supportive & Palliative Care 2012;2:5–6.
review of the perspectives of recipients and tions remain regarding effi cacy, effective- health professionals on care provision. J Card Fail 2011;17:231–52.
REFERENCES
Currow DC. Why don’t we do more rigorous
failure care is no less worthy of rigorous 1. Jaarsma T, Beattie JM, Ryder M, et al. Palliative
clinical research so that we can stop experimenting care in heart failure: a position statement from on patients? J Palliat Med 2010;13:636–7.
BMJ Supportive & Palliative Care March 2012 Vol 2 No1 Subcutaneous furosemide in advanced
heart failure: has clinical practice run ahead
of the evidence base?

James M Beattie and Miriam J JohnsonBMJ Support Palliat Care 2012 2: 5-6 originally published onlineNovember 29, 2011doi: 10.1136/bmjspcare-2011-000199 Updated information and services can be found at: References
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