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# Furosemide
## Overview
Furosemide is a potent loop diuretic used for the management of edema associated with heart failure, cirrhosis, and renal disease, as well as for hypertension.
## Primary Indications
* Edema (e.g., congestive heart failure, hepatic cirrhosis, renal disease)
* Hypertension
## Adult Dosing
### Edema
* **Oral:** 20 mg to 80 mg once daily. If no response, may increase by 20 mg to 40 mg every 6-8 hours. Doses up to 600 mg daily have been used in severe cases, but typically the lowest effective dose is preferred.
* **Intravenous (IV) or Intramuscular (IM):** 20 mg to 40 mg once daily. If no response, may increase by 20 mg to 40 mg every 2 hours. Doses up to 200 mg in a single injection may be required in severe edema.
### Hypertension
* **Oral:** 40 mg twice daily. Often used in combination with other antihypertensives.
## Pediatric Dosing
### Edema
* **Oral:** 1 mg/kg to 2 mg/kg once daily, not to exceed 6 mg/kg/day. Doses may be given once or twice daily.
* **Intravenous (IV) or Intramuscular (IM):** 1 mg/kg once daily, not to exceed 20 mg/dose. May increase by 1 mg/kg every 2 hours. Doses up to 6 mg/kg/day may be needed for severe edema.
## Dose Adjustments
* **Renal Impairment:** May require higher doses due to decreased renal excretion. Monitor for efficacy and toxicity.
* **Hepatic Impairment:** May require lower doses due to altered metabolism and increased sensitivity. Monitor for electrolyte imbalances.
## Contraindications
* Anuria
* Hypersensitivity to furosemide or sulfonamides
## Adverse Effects
* **Common:** Dizziness, lightheadedness, orthostatic hypotension, hearing loss (especially with rapid IV administration or high doses), electrolyte imbalances (hypokalemia, hyponatremia, hypochloremia, hypomagnesemia, hypocalcemia), hyperglycemia, hyperuricemia.
* **Rare:** Aplastic anemia, thrombocytopenia, Stevens-Johnson syndrome.
## Key Drug Interactions
* **Aminoglycosides and other ototoxic drugs:** Increased risk of ototoxicity.
* **ACE inhibitors/ARBs:** Increased risk of hypotension and hyperkalemia.
* **NSAIDs:** May reduce the diuretic and antihypertensive effects.
* **Lithium:** Increased lithium levels and risk of toxicity.
* **Digoxin:** Increased risk of digoxin toxicity, especially in the presence of hypokalemia.
* **Potassium-sparing diuretics:** May be used to counteract potassium loss, but monitor for hyperkalemia.
## Monitoring
* Electrolytes (sodium, potassium, chloride, magnesium, calcium)
* Renal function (BUN, creatinine)
* Blood pressure
* Urine output
* Hearing (especially with high doses or IV administration)
* Blood glucose (in diabetic patients)
* Uric acid (in patients with gout)
## Clinical Pearls
* Administer oral furosemide with food or milk to minimize gastrointestinal upset.
* IV furosemide should be administered slowly (e.g., over 30-60 minutes) to reduce the risk of ototoxicity and hypotension. Rapid bolus injection can cause profound hearing loss.
* For patients with severe edema, a continuous IV infusion may be more effective than intermittent boluses.
* Monitor for signs and symptoms of dehydration and electrolyte depletion.
* Furosemide can cause photosensitivity; advise patients to use sun protection.
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*Please verify the current prescribing information for the most up-to-date recommendations.*
