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Today's VeTerinary PracTice | January/February 2016 | tvpjournal.com PracTicaL TecHniQUes FroM THe naVc insTiTUTe Peer reviewed 102 diuretic effcacy occurs when diuretic delivery to the kidney is in the appropriate range. as shown in Figure 4, diuresis persists for 3 to 5 hours following once-daily administration. Using this dose of furosemide once daily, there is no risk for toxicity and the time in the therapeutic range is maximized. When standard doses of diuretics become inadequate to maintain the patient's quality of life, several strategies can be used, such as increasing dosage, increasing frequency of administration, adding new drugs (ie, sequential nephron blockade with such agents as hydrochlorothiazide and spironolactone), or changing to another drug (eg, torsemide or bumetanide) to boost diuresis (Figures 5 and 6). RAAS Activation Whereas furosemide is known to activate the raas (Figure 1 and Table 1), the reason for high plasma aldosterone concentrations associated with use of torsemide is less clear. although torsemide may activate the raas, evidence suggests that serum aldosterone levels may be elevated because of TAblE 3. monitoring Patients on loop diuretics aT home* Appetite body weight Heart rate Respiratory rate (< 30 breaths/min at home) Signs of congestion (pulmonary edema and ascites) each oFFice visiT Appetite b ody weight Heart rate Respiratory rate Signs of congestion (pulmonary edema and ascites) Packed cell volume/total protein Timing For sPeciFic ParameTers Serum electrolyte concentrations Renal values (blood urea nitrogen [ b UN] and creatinine) days 7 to 14; then as need- ed (sooner if underlying kidney disease present) Electrocardiography (routine, or if arrhythmia auscultated on physical examination) Q 6 to 12 months unless a specifc reason identifed Systolic blood pressure (address if < 100 mm Hg, or if dog is weak or syncopal) Q 6 to 12 months or if symptomatic for hypoten- sion N-terminal of the prohormone brain natriuretic peptide 1. i nitially 2. a fter patient stabilizes 3. Q 3 to 12 months Urinary aldosterone-to-creatinine ratio i nitially , and when signs of congestion recur *Owner should report results of these parameters to veterinarian once per week FIGURE 3. Crossover study performed in normal dogs that compared urine volume of dogs receiving oral furosemide (2 mg/kg Q 12 H) and torsemide (0.2 mg/kg Q 12 H) acutely and after 14 days of treatment. In the dogs receiving torsemide, note the higher peak at days 1 and 14, slightly later peak, and greater duration of enhanced urine fow compared with dogs that received furosemide. Most important, in the dogs receiving furosemide, note the decline in diuresis on day 14 compared with the lack of resistance on day 14 in dogs receiving torsemide.