Home Monitoring Kits May Aid Diuretic Dosing

Diuretic doses in patients with heart failure could be down-titrated effectively using a simple, noninvasive, home-based monitoring system, according to findings from a pilot study presented at the Heart Failure Association of the European Society of Cardiology (HFA-ESC) 2025 Congress in Belgrade, Spain, and published in the European Journal of Heart Failure.

International guidelines recommend loop diuretics for relieving symptoms of fluid overload in patients with heart failure. However, the dose should be lowered as quickly as possible to prevent potential deleterious effects of diuretics, said Evelyne Meekers, MD, lead author of the new study called EASY-STOP.

“Currently, optimal measures for diuretic titration are lacking,” said Meekers, a cardiologist at Ziekenhuis Oost-Limburg Hospital in Genk, Belgium. Pulmonary artery pressure sensors are effective but also invasive and costly to implement, she added.

Meekers and her colleagues designed EASY-STOP to examine whether the use of a home-based test kit for urinary sodium could guide clinicians in effectively down-titrating doses of diuretics. The study enrolled 50 adults with stable heart failure who performed monitoring of sodium levels using the wand-type point-of-care sensors.

Subjects took urine samples twice daily (first urinary void and 2 hours after a diuretic dose) for 1 week while maintaining their diuretic dose. Over the following 3 weeks, they continued the sampling while clinicians attempted to reduce or discontinue the diuretic as symptoms allowed.

Increases in the excretion of urinary sodium in the first void of the day were an indicator of successful reduction in the dosage of diuretic, the researchers found. But the lack of an increase in sodium excretion suggested a need to escalate the diuretic dose.

Of the 62 down-titrations of diuretics performed by Meekers’ group, 34 (55%) were successful, while 28 (45%) required reinitiation of the previous dose. Factors associated with unsuccessful down-titration included an increase in right ventricular systolic pressure > 10 mm Hg (54%), an increase in New York Heart Association class of 1 or more (50%), presence of edema (46%), weight gain (46%), and an increase in diastolic dysfunction (29%).

According to a 2019 position statement in the European Journal of Heart Failure, diuretic dosing should be individualized in patients with heart failure, using dynamic adjustments over time to achieve the lowest effective dose. Failure to reduce diuretic doses when appropriate may lead to consequences such as:

• Hypotension and renal dysfunction, which may limit up-titration of guideline-directed medical therapy (GDMT), particularly renin-angiotensin-aldosterone system and SGLT2 inhibitors.
• Chronic intravascular volume depletion, which may impair renal perfusion and contribute to progressive renal dysfunction.
• Neurohormonal activation, which can counteract the benefits of GDMT.
• Electrolyte disturbances (eg, hypokalemia or hyponatremia), which increase the risk for arrhythmias and the need for hospitalization.
• Impaired quality of life from symptoms such as dizziness, fatigue, and orthostatic hypotension.

“When it comes to heart failure GDMT, three of the four pillars have diuretic effects,” said Glenn Herrington, PharmD, a certified cardiac clinical pharmacist at Novant Health Heart & Vascular Institute in Wilmington, North Carolina. These pillars are angiotensin receptor-neprilysin inhibitors, SGLT2 inhibitors, and mineralocorticoid receptor antagonists. “Clinicians must be mindful of this when implementing and titrating doses, as this typically does require the de-escalation of loop diuretics,” Herrington said.

However, finding the best dose for the patient can be challenging. Standard methods for adjusting diuretic doses require patients to be educated and actively involved in their care, Herrington said. “Patients need to know how to identify the signs of over-diuresis. During the implementation-titration phase, patients should keep daily weights, monitor blood pressure and pulse rate, and know how to adjust their loop diuretic accordingly.”

Laboratory values should be obtained 1-2 weeks after medication changes to monitor renal function and electrolytes, Herrington recommended, while levels of N-terminal pro-B-type natriuretic peptide levels may be used to assess volume status.

“In some cases, patients may not be able to be as engaged in their care,” Herrington said. “That is when other methods for monitoring volume status may be useful. For patients who are not good candidates for noninvasive monitoring, point-of-care urinary sodium monitoring may be an option for guiding diuretic dosing.”

For clinicians who elect to use home sodium monitoring, Meekers stressed the need for clear patient education on the use of home monitoring materials, recognizing symptoms, and setting realistic expectations about the time commitment and possible failure of down-titration.

“After validation from larger studies, we believe the findings of the EASY-STOP study could meaningfully change clinical practice regarding diuretic down-titration in heart failure,” she said. “Ultimately, the hope is that such an approach will help shift the focus toward a more individualized and long-term optimization of heart failure care.”

The sources in this story reported having no financial conflicts of interest.

Katherine Wandersee has more than 30 years’ experience as a medical writer for professional medical audiences.