In medicine, we're often led to believe that "more is better." More interventions will result in better outcomes. More monitoring will result in earlier detection. More education will improve adherence. But our acceptance of the "more is better" philosophy as a universal truth could lead us astray.
For example, in hypervolemic patients, our referring colleagues urge us to diurese these patients as quickly as possible, using all available methods at our disposal. Once the diuresis has begun, we're often cajoled into increasing its frequency and/or intensity. More diuretics archives euvolemia faster and results in better outcomes for the patient, right?
Let's look at this more closely by analyzing two randomized trials on loop diuretic administration in acute decompensated heart failure: DOSE and DRAIN.
In DOSE, which was published at the beginning of the last decade, nearly 300 symptomatic patients received either continuous infusion or intermittent bolus of furosemide(every 12 hours) and either high- or low-dose furosemide to see whether a particular mode and/or dose of loop diuretic would achieve clinical improvement after 72 hours of therapy. The investigators included two primary endpoints: efficacy based on patient global assessment of symptoms (a survey) and safety based on the change in serum
