I have seen the prescribing cascade happen in clinical practice far too many times! One of those classic examples is heart failure. A patient is placed on a new medication that contributes to edema and heart failure. With a period of days to weeks, that patient is then placed on diuretics or doses have had to be escalated. With escalating doses of diuretics, we run an increased risk for dehydration, renal impairment, and electrolyte imbalances. In no particular order, here are 5 classic medications to avoid in heart failure.

Medications to Avoid in Heart Failure

Pioglitazone

Pioglitazone (podcast) isn’t used terribly often for diabetes. In addition to fluid retention, it can cause weight gain which is not desirable in our type 2 diabetes patient population. With plenty of alternatives now, it shouldn’t be terribly difficult to find an alternative agent to lower blood sugar.

NSAIDs

This can be a tough one. We want to avoid NSAIDs in heart failure, but you will have some patients where acetaminophen is a non-starter. In addition, opioids have plenty of risks. Non-traditional analgesia like gabapentin and pregabalin can exacerbate heart failure as well. If there isn’t a good alternative to an oral NSAID, be sure to limit duration and dose as best as possible.

Gabapentin/Pregabalin

With the challenge of analgesia and particularly nerve pain, we don’t have a ton of medication options. In a patient with heart failure, we might need to look a little closer at using an SNRI prior to gabapentin or pregabalin.

Calcium Channel Blockers

Calcium channel blockers like amlodipine are typically very well tolerated. If adverse effects are encountered, one of them is likely to be edema. We have quite a few options for blood pressure medications so hopefully we can find a suitable alternative. This is a dose-dependent effect so if we can’t get by without a CCB, make sure the dose is the minimum effective.

Cilostazol

Cilostazol is most often used in the setting of peripheral vascular disease. It is contraindicated in patients with severe heart failure. The benefit of this medication in a patient with heart failure is unlikely to outweigh the risk.

Can you think of any others you’d like to add to the list of medications to avoid in heart failure?

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