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The key is giving them clear instructions
Can your patients regulate their diuretics according to their daily weigh-in? It takes some specific instruction about what they should do every day and how to react when they are gaining weight from fluid retention. But doctors say what patients know how to do at home can do a lot to keep a handle on their condition.
"I think it’s an important part of managing the disease," says Jay N. Cohn, MD, professor of medicine at the University of Minnesota in Minneapolis and author of an article on the management of chronic heart failure (N Engl J Med 1996; 335:490-498).
"The day-to-day management of the diuretic is something patients can do at home," he says. "That tends to keep people out of the hospital, before they begin to decompensate. Anyone can be educated about his disease and how to manage his medication," says Cohn. "It’s just like diabetic patients can be taught to regulate their insulin."
Self-regulation begins by establishing the patient’s ideal body weight. Cohn says the ideal weight is where the patient is stable and has normal central venous pressure. "That is the weight you want to maintain," he says.
Then, give the patients simple instructions on what to do if they find they have gained two or more pounds since they weighed themselves the previous day. Usually it means taking more medication. "Often, patients have what’s called a kicker,’" Cohn says. That’s the extra medication taken to address the weight gain from fluid retention. When patients are taking a daily loop diuretic, their doctors may instruct them to take an extra one when their weight increases, until the ideal weight is restored.
When the weight goes down again, the patient may not remember to go back to the original dosage. For this reason, it may be easier for the patient to remember to keep the daily loop diuretic constant and use a different medication as the kicker.
"I find it is easier to use metolazone intermittently, rather than change the loop diuretic, but that is an individual decision," Cohn says. He adds that it works like a thiazide, at a different level of diuresis. The kicker is taken until the patient returns to the ideal weight, then only the regular daily plan is followed again. Patients continue to take their daily diuretic as well, unless told otherwise by the physician.
Also, when choosing the diuretic, make sure you understand how it affects that particular patient and how much it takes to get the responses you’re looking for, says Jim Fitzpatrick, MD, clinical assistant professor of cardiology at Thomas Jefferson Medical Center in Philadelphia.
This is true for both the daily dose and the kicker, he says. That way, doctors know the daily dose should be effective and the response diuretic will be able to start working on the extra fluid retention.
Fitzpatrick says he knows many patients who have been able to do this home regulation. He notes that some patients like to have a contact person to call at the doctor’s office, such as a telemanager or a nurse practitioner, just to confirm they are doing the right thing. "They’ll say, Here’s what I weigh, and here’s what I plan to do.’"
Cohn says doctors can cut down on those types of calls by giving the patients clear information and instructions during the office visit. Patients will know they are doing the right thing because it was discussed during the appointment.
What helps even more is to have the instructions written out so they don’t have to commit it all to memory and call when they forget what to do. Then, by making daily weighing a part of the morning routine before getting dressed, at the same time of the day, they become comfortable with it. Deciding the diuretics to take for the day becomes as routine as the weigh-in.
Cohn and Fitzpatrick advise physicians to remember the following points:
- "When you have a patient with sodium retention, it is important to check serum electrolytes and renal function each month or every other month," Cohn says.
- When patients take the kicker, remember that potassium levels may drop. If they take a supplement to maintain potassium, they may need to increase that, too, or eat more fruit if they are maintaining levels with diet alone. Cohn says one banana, for example, has about 10 milliequivalents of potassium, about the same as a potassium supplement.
Potassium regulation is "a very individualized" thing, he says, therefore maintenance and response strategies must be tailored to each patient. (See related box on potassium-rich foods, p. 17.) Patients may also lose potassium if they have diarrhea or have been vomiting, so instructions should cover these situations as well.
- Prepare the patient before starting the self-regulation regimen, says Fitzpatrick. The physician should make sure the patient is educated about the condition and is motivated to take some responsibility with the daily management of the disease.
- Remember to get a sense of how compliant the patient will be and how the diuretics will affect each particular patient.
(For more information on patient compliance, see related stories, CHF Disease Management, January 1999, pp. 8-12.)