Target Audience:

Who should attend:

• Clinical faculty from the University of Pittsburgh School of Pharmacy
• Clinical staff pharmacists employed by the University of Pittsburgh Medical Center and deployed throughout the hospital campus in unit based roles and centrally in the department of pharmacy's main pharmacy
• Student pharmacy interns currently working within the department of pharmacy
• Certified Pharmacy Technicians

Abstract
Numerous patient populations exist where edema and fluid overload are complications of their specific disease state. A non-exhaustive list of these populations include the critically ill, those with liver cirrhosis, and those with congestive heart failure. In situations of fluid overload, fluid management becomes a crucial aspect of the patient’s overall treatment plan. Loop diuretics are commonly used to manage hypervolemic patients, but the extent to which they are used is highly variable based on provider and interdisciplinary team preference. Another agent that is commonly employed as an adjunct therapy to loop diuretics is albumin solution. Although albumin solution is a colloidal fluid known to draw fluid intravascularly, its utility in combination with loop diuretics still has many uncertainties. In 1987, the first proposal of increased efficacy with albumin and loop diuretic coadministration compared with loop diuretics alone was published, with an emphasis on the pharmacokinetic interaction between the two agents. As time has progressed, albumin and loop diuretic combination therapy is commonly utilized in those who are deemed “diuretic resistant”. Despite some viewing albumin as a benign agent with limited downfalls, the potential for adverse events in addition to cost considerations for its use are important factors to consider. For the purposes of this presentation, literature surrounding the use of albumin and loop diuretic combination therapy will be explored, with specific focus on the pharmacokinetic interaction between these two agents and the difference in outcomes that may be present when using combination therapy in comparison to loop diuretics alone.

Educational Objectives:

Upon successful completion of this continuing pharmacy education program, the participant should be able to:

• Explain the pharmacokinetic interaction between albumin and loop diuretics and how that may affect diuretic efficacy
• Identify available literature for combination therapy with albumin and a loop diuretic in the setting of edema.
• Discuss the literature for combination therapy with albumin and loop diuretics in the treatment of edema given a patient case
  

Pharmacy Continuing Education Credits In support of improving patient care, the University of Pittsburgh is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. The assigned universal program number(s) is JA4008223-0000-23-111-H01-P.  This knowledge-based activity provides 1 contact hours of continuing pharmacy education credit. Disclaimer Statement:  The information presented at this activity represents the views and opinions of the individual presenters, and does not constitute the opinion or endorsement of, or promotion by, the UPMC Center for Continuing Education in the Health Sciences, UPMC / University of Pittsburgh Medical Center or Affiliates and University of Pittsburgh School of Medicine.  Reasonable efforts have been taken intending for educational subject matter to be presented in a balanced, unbiased fashion and in compliance with regulatory requirements. However, each program attendee must always use his/her own personal and professional judgment when considering further application of this information, particularly as it may relate to patient diagnostic or treatment decisions including, without limitation, FDA-approved uses and any off-label uses.

Suggested Additional Reading & Joint Accreditation Statement - Note: This Accreditation Statement Supersedes All Other Statements:

Suggested Additional Reading:

1. Moman RN, Gupta N, Varacallo M. Physiology, Albumin. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459198/
2. Huxel C, Raja A, Ollivierre-Lawrence MD. Loop Diuretics. [Updated 2021 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546656/
3. Duffy M, Jain S, Harrell N, et al. Albumin and furosemide combination for management of edema in nephrotic syndrome: A review of clinical studies. Cells. 2015;4(4):622–30.
4. Pichette V, Geadah D, Souich P. The influence of moderate hypoalbuminaemia on the renal metabolism and dynamics of furosemide in the rabbit. Brit J of Pharm. 1996;119(5):885–90.
5. Lee TH, Kuo G, Chang C-H, et al. Diuretic effect of co-administration of furosemide and albumin in comparison to furosemide therapy alone: An updated systematic review and meta-analysis. PLOS ONE. 2021;16(12): 1-16.
6. Inoue M, Okajima K, Itoh K, Ando Y, Watanabe N, Yasaka T, et al. Mechanism of furosemide resistance in analbuminemic rats and hypoalbuminemic patients. Kidney International. 1987;32(2):198–203.
7. Gentilini P, Casini-Raggi V, Fiore GD, et al. Albumin improves the response to diuretics in patients with cirrhosis and ascites: Results of a randomized, controlled trial. J Hepat. 1999;30(4):639–45.
8. Malasani N, Gorski CJ, Horlander JC, et al. Effects of albumin/furosemide mixtures on responses to furosemide in hypoalbuminemic patients. J Amer Society of Nephr. 2001;12(5):1010–16.
9. Martin GS, Mangialardi RJ, Wheeler AP, Dupont WD, Morris JA, Bernard GR. Albumin and furosemide therapy in hypoproteinemic patients with acute lung injury*. Critical Care Medicine. 2002;30(10):2175–82.
10. Doungngern T, Huckleberry Y, Bloom JW, et al. Effect of albumin on diuretic response to furosemide in patients with hypoalbuminemia. American J of Crit Care. 2012;21(4):280–6.
11. Kitsios GD, Mascari P, Ettunsi R, et al. Co-administration of furosemide with albumin for overcoming diuretic resistance in patients with hypoalbuminemia: A meta-analysis. J of Crit Care. 2014;29(2):253–9.
12. Wilcox CS, Testani JM, Pitt B. Pathophysiology of diuretic resistance and its implications for the management of Chronic Heart Failure. Hypertension. 2020;76(4):1045–54.

Joint Accreditation Statement - this statement supersedes any other statement on this page: In support of improving patient care, the University of Pittsburgh is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Pharmacy (CPE)  This knowledge-based activity provides 1.0 contact hours of continuing pharmacy education credit.
Other Healthcare Professionals: Other health care professionals will receive a certificate of attendance confirming the number of contact hours commensurate with the extent of participation in this activity.