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# Furosemide
## Overview
Furosemide is a potent loop diuretic used to treat fluid overload (edema) associated with conditions like heart failure, liver disease, and kidney disease. It also treats high blood pressure, often in combination with other antihypertensives.
## Primary Indications
* Edema associated with congestive heart failure, liver cirrhosis, and renal disease.
* Hypertension.
## Adult Dosing
* **Edema:**
* Initial dose: 20-80 mg orally once daily.
* May be increased by 20-40 mg every 6-8 hours as needed.
* Subsequent doses should be adjusted based on response.
* Maximum daily dose: 600 mg.
* **Hypertension:**
* Initial dose: 40 mg orally twice daily.
* Doses may be adjusted based on response.
* Often used in combination with other antihypertensives.
* Maximum daily dose: 600 mg.
Intravenous (IV) or intramuscular (IM) doses are typically similar to oral doses but may be higher in acute situations due to bioavailability differences. The IV dose is usually half the oral dose.
## Pediatric Dosing
* **Edema and Hypertension:**
* **Oral:** 1-4 mg/kg orally once daily. Doses may be increased by 1-2 mg/kg every 6-8 hours as needed. Maximum daily dose: 6 mg/kg.
* **IV/IM:** 1 mg/kg IV/IM once daily. Doses may be increased by 1 mg/kg every 2 hours as needed. Maximum initial dose: 2 mg/kg. Subsequent doses should not exceed 6 mg/kg/day.
Dosing in neonates and premature infants may require special consideration due to immature renal function.
## Dose Adjustments
* **Renal Impairment:** Dose may need to be increased in patients with renal impairment to achieve a similar diuretic effect. However, caution is advised as they may be more susceptible to adverse effects. Monitor electrolytes and renal function closely.
* **Hepatic Impairment:** Use with caution. Dose reduction may be necessary.
## Contraindications
* Anuria.
* Known hypersensitivity to furosemide or sulfonamides.
* Hepatic coma and severe electrolyte depletion.
## Adverse Effects
* **Common:** Dizziness, lightheadedness, electrolyte imbalances (hypokalemia, hyponatremia, hypochloremia), dehydration, hypotension.
* **Serious:** Ototoxicity (hearing loss, tinnitus - especially with rapid IV administration or high doses), hyperuricemia (gout), hyperglycemia, photosensitivity, Stevens-Johnson syndrome, aplastic anemia, pancreatitis.
## Key Drug Interactions
* **Aminoglycosides and other ototoxic drugs:** Increased risk of ototoxicity.
* **ACE inhibitors and ARBs:** Increased risk of hypotension and renal dysfunction.
* **NSAIDs:** May reduce the diuretic and antihypertensive effects; increased risk of renal impairment.
* **Lithium:** Increased risk of lithium toxicity due to decreased renal excretion.
* **Corticosteroids:** Increased risk of electrolyte depletion, particularly hypokalemia.
* **Digoxin:** Increased risk of digoxin toxicity in the presence of furosemide-induced hypokalemia.
## Monitoring
* Electrolytes (sodium, potassium, chloride)
* Renal function (BUN, creatinine)
* Blood pressure
* Urine output
* Hearing function (especially with prolonged therapy or high doses)
* Blood glucose (in diabetic patients)
* Uric acid levels
## Clinical Pearls
* Administer oral furosemide with or without food.
* For IV administration, give slowly to minimize the risk of ototoxicity.
* Rapid IV administration of furosemide can cause transient hearing loss.
* Monitor for signs of dehydration and electrolyte imbalances closely, especially in elderly patients or those with significant fluid loss.
* Potassium supplementation may be necessary to prevent hypokalemia.
* Furosemide can cause increased frequency of urination; counsel patients accordingly.
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*This information is intended for clinical professionals. Always consult the current prescribing information and relevant literature for complete details and to confirm dosages and safety information before use.*
