A 72‑year‑old man with advanced COPD and heart failure has severe fluid overload with bilateral pleural effusions and peripheral oedema. His renal

Question

A 72‑year‑old man with advanced COPD and heart failure has severe fluid overload with bilateral pleural effusions and peripheral oedema. His renal function is declining (eGFR 15 mL/min/1.73 m²). He is on furosemide 250 mg OD and spironolactone 50 mg OD. He is not responding adequately to diuretics. What additional diuretic strategy is most appropriate to overcome diuretic resistance?

Accepted Answer

Sequential nephron blockade—add metolazone 2.5 mg OD (thiazide‑like diuretic acting at distal convoluted tubule) to existing loop diuretic

Answer

Switch to IV mannitol for osmotic diuresis

Answer

Stop all diuretics and use paracentesis only

Answer

Increase furosemide to 1000 mg OD

Answer

Add a second loop diuretic (bumetanide)

Sequential Nephron Blockade for Diuretic Resistance — SCE Palliative Medicine MCQ