The team is relatively stable, but most things remain on hold until Monday. Our patients were improving yesterday. Here was our big discussion point of the day.
We have a patient with ascites and a new cirrhosis diagnosis. We first proved that he had secondary hyperaldosteronism using the transtubular potassium gradient. We started spironalactone and furosemide. Because the patient did not have a significant response to oral furosemide 40 mg, I raised the question of trying bumetanide 1 mg instead.
Here was my reasoning. Both loop diuretics are currently generic drugs available at WalMart prices. Furosemide has inconsistent absorption, ranging from 10%-90% across patients. Bumetanide has consistent absorption in the range of 80-90%. The estimated equivalence ratio is 40 mg to 1 mg.
Given the more predictable absorption, we should wonder whether we should abandon furosemide and switch to bumetanide as our loop diuretic of choice. I believe if both diuretics were released simultaneously, we would clearly choose bumetanide.
We decided to try bumetanide 1 mg b.i.d. I will report back on the impact of that decision. For more on loop diuretics, I highly recommend a colleague's paper – A Comprehensive Review of the Loop Diuretics: Should Furosemide Be First Line?
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Why not Torsemide? Torsemide causes much more diuresis and dont have much effect on electrolytes especially hypokalemia as compared to Furosemide.
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