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An evaluation of the use of subcutaneous furosemide in end stage heart failure in the West

Reynolds, A., Sanyal, N., Gray, A.

Background and Objectives

With 1.4% of the UK population living with the condition(1), Chronic Heart Failure (CHF) is a leading cause of morbidity and mortality, and a growing public health problem. When decompensation occurs, some patient develop symptoms of dyspnoea and oedema which are refractory to standard oral diuretic therapy, due to bowel oedema causing poor enteral absorption(2). With recurrent and often unpredictable episodes of decompensation, patients may experience a ‘revolving door’ phenomenon of repeated hospital admissions for intravenous rescue treatment(3). Some patients may become medically unfit to receive intravenous bolus diuretics, due to poor venous access or reactive hypotension. As a progressive disease, the ‘end’ stage often correlates to a general decline as well as repeated admissions and increasing symptom burden(5). For patients nearing the end of life, preferred place of care (and indeed, death), as well as alleviating distressing symptoms, are matters of high priority.

Subcutaneous Furosemide (SCF) has been used increasingly in local pockets of community settings within palliative care (including homes and hospices) for many years(6), but not ubiquitously; often dependent upon the experience of local practitioners. However, SCF can provide significant symptom relief, with the added benefits of prevention of hospital admission and patient satisfaction with this.

The evidence base remains scanty, with just a handful of relevant placebo-controlled randomised controlled trials, case series and case reports over the past decade(7).

We aimed to assess clinician confidence and experience of using SCF within the West Midlands.

Method

A literature review on the topic kick-started the project and was conducted in August 2019, and the following year an online pilot survey was sent to local Palliative Care doctors assessing experience and confidence in using SCF, as well as advantages and barriers to use.
Building on this, in January 2021, a 12-question Survey Monkey questionnaire was designed and sent out via e-mail to clinicians working in palliative care across the West Midlands using our trainee-led research collaborative (WMCares) platform. Participants were also able to record anecdotes of SCF use.
The results were analysed qualitatively and quantitatively.

Results

General: A total of 36 individuals responded with a breakdown of 89% working within palliative care. 78% of responders had prescribed or administered subcutaneous furosemide but the majority (28%) did this once a year or less. By clustering qualitative responses into themes, the main advantage of this route of administration was reported as avoidance of hospital admission.

Limitations of use: The majority of respondents reported no drawbacks from the use of furosemide via this route, however the frequency of prescribing this was low. Another significant theme in relation to drawbacks of SC furosemide was that of staff familiarity and training issues becoming a block to its use in the community.

Prescriber confidence: The average self-rated measure of confidence in prescribing furosemide SC was 62 with responses spanning the whole range of 0-100. The top 3 cited reasons for lack of confidence were dosing and conversion rates, lack of experience and on the subject of monitoring.
Practical challenges: 47% of responders reported logistical and/or practical issues with SC furosemide with the main themes being syringe driver volume limitations capping doses, access to the drugs in the community and staff training.

Doses used: When SC furosemide had been prescribed, doses ranged from 40mg to 250mg with the majority of cases using 240mg (24%). The majority of responders reported seeing some benefit using furosemide this way with 81% reporting that it enabled the avoidance of a hospital admission.

Monitoring: The degree of monitoring varied widely with the majority of responders (53%) carrying out monitoring of renal function. 48% monitored blood pressure. Of those that responded, 63% reported no site reactions.

Conclusion

This study demonstrated that there is an awareness amongst palliative care healthcare professionals in the West Midlands of the use SCF as an effective means of managing symptoms in patients with CHF. Despite this, the majority of respondents reported SCF to be used infrequently and also acknowledged a lack of familiarity with how to utilise it in their day to day work. Reports of limited access to training and lack of confidence has hindered a significant number of our respondents. They instead reported a lack of standardised practice in dosing and subsequent monitoring.

However, clinicians that had used it had witnessed it to be effective in managing the complex symptoms of this patient cohort. They also highlighted the practical benefits of hospital admission avoidance, and allowing a patient to continue their care in their preferred place, a priority for both patients and the staff caring for them.

Going forward
With the incidence of CHF being on the rise, and given the associated significant symptom burden, it is important that clinicians are equipped with not only the tools to manage symptoms effectively, but also the confidence to know how to use them. SCF has the potential to benefit many more patients, but for this to be realised, we suggest the following:
-Improving confidence in prescribing and administration of SCF by making training opportunities available to clinicians
-Further research into how to optimise, deliver and monitor SCF therapy in a community setting

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