Subcutaneous Furosemide, a Novel Therapy With Potential to Reduce Heart Failure Burden

Heart failure (HF) remains a global health challenge, with an urgent need to identify therapies that can reduce disease burden. A first-line agent in HF, furosemide, a loop diuretic, is regularly used for volume management in chronic HF patients. As maintenance therapy, oral furosemide is convenient to administer and efficacious. However, in decompensated HF with volume overload, oral furosemide becomes significantly less efficacious because of decreased absorption secondary to intestinal edema. Therefore, volume-overloaded HF patients are often hospitalized to facilitate administration of intravenous (IV) furosemide. While a subset of these patients may truly require hospitalization for stabilization and rapid diuresis with IV furosemide, a significant portion may not require hospitalization if an efficacious alternative to oral furosemide were available. Consequently, researchers have developed novel formulations of subcutaneous (SC) furosemide that can be self-administered as an alternative to oral furosemide. Numerous small randomized controlled trials demonstrated the safety and efficacy of SC furosemide, with equivalent diuresis compared with IV furosemide, resulting in recent Food and Drug Administration approval of multiple SC furosemide formulations. Despite approval, there remains a need for a large, randomized controlled trial to elucidate guidelines regarding the outpatient use of SC furosemide. Nevertheless, SC furosemide is not intended as a replacement for IV furosemide in patients requiring hospitalization for urgent diuresis due to complications related to volume overload. Instead, SC furosemide should serve as an alternative to oral furosemide in the outpatient setting in stable, volume-overloaded patients, thereby reducing the burden of unnecessary HF hospitalizations.