Diuretics demand discussion in heart failure management

To assess a patient's ability to adhere to a diuretic regimen, consider the patient's age, level of education, and severity of symptoms, as well as health literacy, and any comorbidities.

Adhering to a heart failure medication regimen isn't simple, Audrey C. Kleet, MS, ACNP-BC, told attendees at the annual meeting of the Heart Failure Society of America, held in Philadelphia in September.

“Most of our patients are not on monotherapy. How could they be? They have chronic heart failure. They're on at least three guideline-directed medical therapies, plus diuretics, most likely,” she said.

To ensure patients follow their diuretic regimen use high-tech systems such as reminders on a smartphone to take the pill and low-tech systems such as recording doses in a diary to review at the nex
To ensure patients follow their diuretic regimen, use high-tech systems such as reminders on a smartphone to take the pill, and low-tech systems such as recording doses in a diary to review at the next office visit. Image by Chainarong Prasertthai

The management of diuretic medications in particular requires creative communication strategies, according to Ms. Kleet, chief heart failure and transplant officer at New York Presbyterian-Columbia University Irving Medical Center in New York City.

“We really want to put that spotlight on education, want to help them understand the heart failure disease process, the roller coaster that they may be on,” she said. “We want to personalize for the patient that's in front of us or on the phone. We want to help them learn more about themselves, and we're learning about them, too.”

There's a long list of things to learn in order to assess a patient's ability to adhere to a diuretic regimen. “The first three major factors are age, level of education, and severity of symptoms. These are the three chief factors that the World Health Organization actually put in their 200-page report that was published in 2003 looking at compliance,” said Ms. Kleet.

Other relevant issues include health literacy, “both in general and the perception of the patient in terms of their health problem or diagnosis, or many problems, as with so many of our patients.” That quantity of comorbidities may also be a determinant, she added.

Exploring a patient's health literacy should include a focus specifically on the diuretic prescription. “Do our patients understand the importance of diuretics in helping them overcome heart failure, or at least acute heart failure? Do they understand why they are being instructed to take them at certain times of the day?” asked Ms. Kleet. “Do they know which pill their diuretic is?”

Health beliefs, as well as understanding, may affect adherence. “Are they really believing what you're telling them about their diagnosis?” she asked. “Do they have disbelief in their diagnosis? Do they trust in the health care system or in you as a health care provider? What are their interpersonal relationships like with health care providers?”

Social circumstances and financial status are also important issues to cover. “Most of the diuretics we're writing for congestive heart failure patients now are affordable, but it doesn't mean they're affordable to this patient. Are they taking the proper dose or are they splitting the dose to save up their meds to stretch out the supply and then reduce their monthly cost for medications? Many times our patients are doing this. We're not asking, so we don't know and they may be very afraid to tell us,” Ms. Kleet said.

The constraints of patients' lives may affect adherence in other ways, too. “We may have patients who are in the work force and it's very uncomfortable for them to take a water pill in the morning prior to going to work. How are they going to get to work without using the bathroom? … When they get to their work, is there a bathroom they can readily access?” she said. “If we don't know the answer to a lot of these questions, we'll have a very difficult time coming up with strategies which will be effective for our patients.”

Clinicians should acknowledge these obstacles and then help find solutions, Ms. Kleet advised.

“Yes, you're going to be running to the bathroom. This is a fact of life on water pills,” she said. “We want to simplify their therapeutic regimen as much as possible, adjusting their dosing times to accommodate their life schedule.”

Once the schedule is set, the next challenge is for patients to remember it. “Even our patients in the lowest socioeconomic classes, most have smartphones. … Help them set up their alarms—that's when they're going to take their water pills,” said Ms. Kleet.

Lower-tech reminders may also be useful. “If we're giving them changes to their medications, particularly their diuretic dosing, we're going to encourage to them to have a journal, a notebook, where they write that down and then bring it back to clinic with them so they can show us. … ‘You called me last Wednesday. We held my water pill for a day, remember, because my weight went down.’”

This record-keeping can help increase patients' engagement in their own care. “That way they can get to see the patterns with us and get to start understanding why we treat them the way we're treating them. That knowledge really is power for them,” said Ms. Kleet.

Encourage patients to analyze their symptoms and signs themselves. “How did you feel when we did this for you, when we up-adjusted or down-adjusted your torsemide, for instance?” she said. “We want to teach them what to measure, how to measure it, and how often to measure it.”

They'll also need to know how to act on those findings. “‘Please call me when … I need to speak to you if …’ But can they get through to us?” asked Ms. Kleet. “Of course, we want to teach them that they have access to us, that we're only a phone call away. And hopefully on the back end, we have some support making sure that those processes to get to us actually work, so that our patients can in fact find us in time of need.”

When appropriate, caregivers should also be included in these discussions, she noted. “We want to be involving them every step of the way, as much as possible, as much as our patients will allow.”

Also consider involving other clinicians, particularly if they have relevant specialty expertise. “Many times our patients are lacking support to be able to manage all of these medications, including their diuretics, and be able to talk about their life stressors and how to manage their life with these medications. So we want to bring in our social workers, our pharmacists, our medical specialists, like our neurocognitive specialists, for instance,” said Ms. Kleet. Depression, anxiety, or cognitive dysfunction can add to the existing challenges of diuretic management.

“Remember as a health care provider that you're not alone, and I think we've done a really good job in the heart failure community in recalling that and recognizing that patients are cared for by a team,” said Ms. Kleet.

On the other hand, this task shouldn't be entirely delegated to other clinicians. “The importance of their diuretics, the possible adverse effects or side effects they could have from their diuretics, the intended consequences, how to live life and still take their meds—patients need to hear from us in the white coats all of these important things. We can't skip out on doing this,” said Ms. Kleet.