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## Furosemide
### Overview
Furosemide is a loop diuretic used to treat edema associated with congestive heart failure, liver cirrhosis, and renal disease, including the nephrotic syndrome. It is also used to treat hypertension, alone or in combination with other antihypertensives.
### Primary Indications
* Edema (congestive heart failure, liver cirrhosis, renal disease)
* Hypertension
### Adult Dosing
* **Edema:**
* Oral: Start with 20-80 mg once daily. The dose may be increased by 20-40 mg every 6-8 hours as needed. Doses may be given once or twice daily. Doses exceeding 80 mg should be carefully titrated. Maximum daily oral dose is typically 600 mg, but higher doses have been used in refractory cases under close supervision.
* Intravenous (IV) or Intramuscular (IM): Start with 20-40 mg once daily. If inadequate response, may increase by 20 mg every 2 hours. Equivalent to oral dose. Maximum IV/IM dose is typically 80-100 mg as a bolus, but continuous infusion may be used in refractory edema.
* **Hypertension:**
* Oral: Start with 40 mg twice daily. Doses may be adjusted based on response. Typically, doses over 40 mg twice daily are not more effective.
### Pediatric Dosing
* **Edema:**
* Oral: 1-2 mg/kg once daily. May increase by 1 mg/kg every 6-8 hours as needed. Maximum daily dose: 6 mg/kg.
* IV/IM: 1 mg/kg once daily. If inadequate response, may increase by 1 mg/kg every 2 hours. Maximum dose: 2 mg/kg or 40 mg total, whichever is less. Doses higher than 40 mg should be given cautiously.
### Dose Adjustments
* **Renal Impairment:** Dose may need to be increased, especially with impaired renal function and hypoalbuminemia. Close monitoring is essential.
* **Hepatic Impairment:** Furosemide can precipitate hepatic encephalopathy in patients with severe liver disease. Doses should be reduced.
### Contraindications
* Anuria
* History of hypersensitivity to furosemide or sulfonamides
### Adverse Effects
Common: Dizziness, lightheadedness, electrolyte imbalance (hypokalemia, hyponatremia, hypochloremia), dehydration, hyperuricemia, hyperglycemia.
Less Common: Ototoxicity (especially with rapid IV administration or high doses), rash, pancreatitis, aplastic anemia, thrombocytopenia, Stevens-Johnson syndrome.
### Key Drug Interactions
* **Aminoglycosides:** Increased risk of ototoxicity and nephrotoxicity.
* **Digoxin:** Increased risk of digoxin toxicity due to furosemide-induced hypokalemia.
* **NSAIDs:** May reduce the diuretic and antihypertensive effect of furosemide.
* **Lithium:** Furosemide can decrease lithium clearance, leading to increased lithium levels and toxicity.
* **Antihypertensives:** Additive hypotensive effects.
### Monitoring
* Electrolytes (sodium, potassium, chloride, magnesium, calcium)
* BUN, creatinine
* Blood pressure
* Urine output
* Serum glucose and uric acid (periodic)
* Hearing (especially with high doses or rapid infusion)
### Clinical Pearls
* Furosemide is a potent diuretic and can lead to significant fluid and electrolyte losses.
* Administer IV furosemide slowly (e.g., over 30-60 minutes) to reduce the risk of ototoxicity.
* Oral administration is generally preferred for chronic management of edema.
* Patients may develop tolerance to the diuretic effect over time.
* Be aware of potential for rebound edema if stopped abruptly.
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*This information is intended for healthcare professionals. Always consult the most current prescribing information and institutional protocols before administering any medication.*
