Subcutaneous furosemide in advanced heart failure: has clinical practice run ahead of the evidence base?

Over the past 20 years, progress in our understanding of the nature and treatment of congestive heart failure due to left ventricular systolic dysfunction has significantly improved the outlook of those diagnosed with this condition and many patients now live longer and more comfortable lives. Comprehensive heart failure care is largely founded on the results of robust randomised clinical trials of drug, device and cardiac surgical interventions which are enshrined as the basis of widely implemented clinical guidelines. Current heart failure treatment may thus be regarded as an example of the application of evidence based medicine.

Despite such developments, heart failure remains burdensome for patients and their families, and is often complicated by prognostic uncertainty and comorbidities common in the typically affected older population. Heart failure still tends to progress inexorably and it is now acknowledged that those with palliative care skills should be central to the multidisciplinary team approach to this ultimately fatal illness.1 Their contribution is predominantly relevant to those with advanced disease or approaching the end of life. Indeed such heart failure patients are increasingly treated by specialist palliative care teams in hospitals, hospices and in the community.

Provision of therapy via the subcutaneous (SC) route is common in palliative care practice for the continuous administration of medication for symptom relief. However, with the exception of opioids such as morphine and hydromorphone, few drugs have randomised controlled data comparing SC and …