Managing Acute Heart Failure: Evidence From the DOSE Trial

Key Takeaways

• High-dose IV furosemide speeds oral transition.
• No renal advantage for low-dose strategy.
• Bolus and infusion equally effective for symptoms.
• Transient creatinine rise not contraindication to high dose.
• Continuous infusion offers no clear benefit in stable patients.

Summary

The DOSE trial compared low‑dose versus high‑dose IV furosemide and bolus versus continuous infusion in 308 stable acute‑on‑chronic heart‑failure patients. High‑dose therapy (≈2.5 × oral dose) increased the proportion switching to oral diuretics by 48 hours without worsening 60‑day outcomes, while renal function differences were transient. No significant interaction was found between dosing strategy and administration mode, indicating bolus and infusion are equally effective for symptom relief. The study clarifies that aggressive diuresis is safe in hemodynamically stable patients.

Pulse Analysis

The acute decompensation of chronic heart failure remains a frequent cause of hospital admission, and loop diuretics are the cornerstone of volume‑offloading therapy. Clinicians have long debated whether to simply double a patient’s oral furosemide dose, to use a higher‑intensity regimen, or to switch from intermittent bolus injections to a continuous infusion. Prior to 2026, evidence was fragmented, leaving many hospitals to rely on institutional habit rather than data. The DOSE (Diuretic Optimization Strategies Evaluation) trial, conducted across 26 North American sites, finally provided a rigorous, factorial comparison of dose intensity and delivery method in a well‑characterized cohort.

The trial enrolled 308 hemodynamically stable patients with baseline oral furosemide 80‑240 mg and randomized them to low‑dose (equivalent to oral intake) or high‑dose (2.5 × equivalent) regimens, each delivered either as twice‑daily boluses or as a continuous infusion. High‑dose therapy doubled the proportion of patients who could be switched to oral diuretics by 48 hours (31 % vs 17 %) without increasing 60‑day mortality. Although the high‑dose arm showed a modest, transient rise in serum creatinine, renal function equalized by two months, dispelling concerns that aggressive diuresis inevitably harms the kidneys.

For hospitalists, the practical takeaway is clear: in stable acute heart failure, escalating the loop diuretic dose to roughly 2.5 × the outpatient amount improves decongestion and short‑term symptom relief, and the choice between bolus and infusion can be guided by logistics rather than efficacy. Continuous infusions may still be reserved for patients with severe diuretic resistance or when precise titration is required. The DOSE findings also underscore the importance of monitoring renal trends rather than reacting to a single creatinine spike, supporting more confident use of high‑dose diuretics in contemporary heart‑failure care.