Other considerations The committee considered the use of IV and subcutaneous diuretics in people with advanced chronic heart failure to be an area of high priority for future research. The committee highlighted that the delivery of these treatments in the community was variable across the country and was dependant on whether or not commissioning for the service was in place. The committee noted that for many advanced heart failure patients, some of whom may be approaching the end of their life, the focus of treatment may shift to symptom relief, admission avoidance, maintaining quality of life and minimising discomfort. These patients may become less responsive to conventional oral doses of loop diuretics and resistance can occur. The committee discussed whether subcutaneous diuretics may be more effective than oral diuretics but this route requires delivery by healthcare professionals. Likewise, IV diuretics could prove to be more effective than oral and subcutaneous diuretics in managing symptoms, but they are invasive, may not be feasible or appropriate in people in the later stages of heart failure. For those reasons, the committee decided to make a research recommendation to establish the added value of IV or subcutaneous diuretics (in terms of its clinical and cost effectiveness) in people with advanced heart failure, with significant peripheral fluid overload, in the community. The committee acknowledged the BHF funded pilot study Report-IV-Diuretics-August-2014.pdf) which consisted of a 2 year project in 10 NHS organisations across the UK in both urban and rural areas to assess Chronic Heart Failure Domiciliary oxygen therapy in people with advanced heart failure NICE 2018. All rights reserved. Subject to Notice of rights. 