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# Furosemide (Oral)
## Overview
Furosemide is a loop diuretic used for the management of edema associated with heart failure, liver disease, and renal disease, including in patients with clinical signs and symptoms of fluid overload. It can also be used as adjunctive therapy in acute pulmonary edema.
## Primary Indications
* Edema (heart failure, liver disease, renal disease)
* Acute pulmonary edema
## Adult Dosing
* **Edema:** Initial dose is typically 20 mg to 80 mg orally once daily. The dose may be titrated up to 600 mg daily in divided doses for patients with severe edema, though doses above 80 mg daily are less effective and may increase adverse effects. Dosing frequency may be adjusted based on response (e.g., every other day or intermittently).
* **Acute Pulmonary Edema:** Initial dose is typically 20 mg to 40 mg orally once. If the patient does not respond adequately within 1 hour, a second dose of 40 mg may be administered. Further doses should be guided by response and may be increased cautiously.
## Pediatric Dosing
* **Edema:** Dosing is highly individualized. Typical initial dose is 1 mg/kg/dose orally once daily. If inadequate response, the dose may be increased by 1 mg/kg/dose every 6-8 hours. Maximum dose is typically 6 mg/kg/day.
## Dose Adjustments
* **Renal Impairment:** In patients with significant renal impairment, higher doses may be required due to reduced renal clearance. However, monitor closely for ototoxicity and further renal deterioration.
* **Hepatic Impairment:** Use with caution. Monitor for electrolyte imbalances and hepatic encephalopathy.
## Contraindications
* Anuria
* Known hypersensitivity to furosemide or sulfonamides
## Adverse Effects
Common: Dizziness, lightheadedness, electrolyte imbalances (hypokalemia, hyponatremia, hypochloremia), dehydration, hypotension, hyperuricemia, hyperglycemia.
Less Common: Ototoxicity (especially with rapid IV administration or high doses), rash, photosensitivity, pancreatitis, gastrointestinal upset.
## Key Drug Interactions
* **Aminoglycosides and other ototoxic drugs:** Increased risk of ototoxicity.
* **NSAIDs:** May reduce diuretic and antihypertensive effects, and increase risk of renal impairment.
* **ACE inhibitors/ARBs:** Increased risk of hypotension and renal dysfunction.
* **Corticosteroids:** Increased risk of electrolyte depletion.
* **Digoxin:** Increased risk of digoxin toxicity due to hypokalemia.
* **Lithium:** Reduced lithium clearance, increasing risk of lithium toxicity.
## Monitoring
* Electrolytes (sodium, potassium, chloride)
* Renal function (BUN, creatinine)
* Fluid balance (weight, intake/output)
* Blood pressure
* Blood glucose (in diabetic patients)
* Uric acid
* Hearing (especially with high doses or concomitant ototoxic agents)
## Clinical Pearls
* Oral administration has a slower onset of action but may provide more sustained diuresis compared to IV.
* Administer in the morning to minimize nocturnal diuresis.
* For edema, intermittent or alternate-day dosing may be used to reduce electrolyte disturbances and tolerance.
* Monitor for signs of dehydration and electrolyte imbalances, particularly hypokalemia, which can predispose to arrhythmias.
* Correct hypokalemia before initiating digoxin or if patient is on digoxin.
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**Disclaimer:** This information is intended for clinical use and is not exhaustive. Always consult the most current prescribing information and relevant literature before making clinical decisions. Verify doses with local protocols.
