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## Furosemide
### Overview
Furosemide is a potent loop diuretic used to treat edema associated with heart failure, liver disease, and renal disease, as well as hypertension.
### Primary Indications
* Edema (pulmonary, peripheral)
* Hypertension (adjunctive therapy)
### Adult Dosing
* **Edema:**
* Initial: 20 mg to 80 mg orally once daily. Dose can be increased by 20 mg to 40 mg every 6 to 8 hours as needed.
* Maintenance: Adjust to the lowest effective dose. May be given once or twice daily.
* Maximum daily dose: 600 mg orally.
* **Hypertension:**
* 20 mg to 40 mg orally twice daily.
* Maximum daily dose: 600 mg orally.
* **Intravenous (IV) or Intramuscular (IM):**
* Initial: 20 mg to 40 mg IV or IM once daily.
* Subsequent doses can be increased by 20 mg every 6 to 8 hours if needed.
* Continuous IV infusion: 4 mg/hour after an initial IV bolus dose.
* Maximum IV/IM daily dose: 600 mg. Doses exceeding 600 mg/day are generally not recommended due to lack of additional benefit and increased risk of ototoxicity.
### Pediatric Dosing
* **Edema/Hypertension:**
* Oral: 1 mg/kg/dose to 2 mg/kg/dose once or twice daily.
* Maximum oral dose: 6 mg/kg/day.
* IV/IM: 1 mg/kg/dose, not to exceed 20 mg per dose once or twice daily.
* Subsequent IV/IM doses may be increased by 1 mg/kg every 6 to 8 hours.
* Maximum IV/IM dose: 40 mg per dose for infants and children. Higher doses (up to 600 mg/day) have been used in specific situations (e.g., acute exacerbations of heart failure) under specialist guidance.
### Dose Adjustments
* **Renal Impairment:** Dose adjustments may be necessary based on response and degree of renal impairment. In patients with severe renal impairment, response may be blunted, and higher doses may be required; however, risk of ototoxicity increases.
* **Hepatic Impairment:** Caution is advised. Dose reduction may be necessary.
### Contraindications
* Anuria
* History of hypersensitivity to furosemide or sulfonamides.
### Adverse Effects
Common: Dizziness, lightheadedness, blurred vision, electrolyte imbalances (hypokalemia, hyponatremia, hypochloremia), dehydration, hypotension, polyuria.
Less Common: Ototoxicity (especially with rapid IV administration or high doses), hyperuricemia, hyperglycemia, rash, photosensitivity.
### Key Drug Interactions
* **Aminoglycosides, other ototoxic drugs:** Increased risk of ototoxicity.
* **NSAIDs:** May reduce diuretic and antihypertensive effects.
* **Antihypertensives:** Additive hypotensive effects.
* **Digoxin:** Increased risk of digoxin toxicity due to furosemide-induced hypokalemia.
* **Lithium:** Reduced renal clearance and increased risk of lithium toxicity.
* **Corticosteroids:** Increased risk of hypokalemia.
### Monitoring
* Electrolytes (sodium, potassium, chloride)
* Renal function (BUN, creatinine)
* Blood pressure
* Urine output
* Auditory function (especially with high doses or concurrent ototoxic agents)
### Clinical Pearls
* Administer IV furosemide slowly (over 30-60 seconds for doses up to 40 mg) to reduce the risk of ototoxicity. Do not exceed 4 mg/minute for infusions.
* Oral administration can be given with or without food.
* Monitor for signs and symptoms of dehydration and electrolyte imbalances.
* Regular monitoring of hearing is recommended, particularly in patients receiving high doses or with risk factors for ototoxicity.
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*This information is intended for healthcare professionals. It is essential to consult the most current prescribing information and relevant clinical guidelines for definitive patient management decisions. Dosing may vary based on individual patient factors and local protocols.*
