What is your answer?

** This was an actual case **

The traditional answer is ethacrynic acid [Edecrin ®]. This is a non-sulfonamide loop diuretic, usually available as IV and oral forms. The problem with this agent is the oral form is not currently available from the only manufacturer (Merck). There is a very limited supply of the IV form. The best info we have from the manufacturer is there may be some oral forms available in early 2003.

There are other loop diuretics such as torsemide, bumetanide but all have warnings or contraindications about using them in patients with allergies/hypersensitivity to sulfonamides. Thiazide diuretics generally don't work in patients with CrCls less than ~30 ml/minute. Metolazone MAY be an option in this patient but is only available in an oral form. (FYI - Metolazone is more effective than other thiazide diuretic but less effective than loop diuretics, maybe due to a more proximal site of action in the nephron). Mercurial diuretics are no longer commercially available and are only of academic interest. Acetazolamide, a carbonic anhydrase inhibitor, has some diuretic effects. It's diuretic effects are rapidly overcome. This would NOT be an option in this patient due to the sulfonamide allergy also. Potassium sparing diuretics (triamterene, spironolactone, amiloride) are rather weak diuretics and probably contraindicated in this patient due to the increased risk of hyperkalemia. Mannitol may be used in early, acute failure but not in generalized edematous states such as CHF. With significant renal dysfunction (as in this patient) the retention of the hypertonic mannitol within the vasculature may cause further volume expansion/fluid retention, worsening CHF and possibly precipitating pulmonary edema. Hemodialysis is an option but usually the final option.