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# Furosemide
## Overview
Furosemide is a potent loop diuretic used to treat edema associated with heart failure, liver cirrhosis, and renal disease, including nephrotic syndrome. It is also used to manage hypertension.
## Primary Indications
* Edema (congestive heart failure, liver cirrhosis, renal disease)
* Hypertension (usually in combination with other agents)
## Adult Dosing
* **Edema:** Oral: 20 mg to 80 mg once daily. May increase by 20 mg to 40 mg every 6 to 8 hours until desired response. Usual dose range 40 mg to 120 mg daily in divided doses. IV/IM: 20 mg to 40 mg once daily. May increase by 20 mg every 2 hours until desired response. Usual dose range 40 mg to 120 mg daily in divided doses. Maximum recommended oral dose is 600 mg/day. Maximum recommended IV dose is 200 mg in a single dose, though higher doses may be used under close monitoring for severe edema.
* **Hypertension:** Oral: 40 mg twice daily. Usually used in combination with other antihypertensives.
## Pediatric Dosing
* **Edema:** Oral: 1 mg/kg to 4 mg/kg per day divided into 1 to 4 doses. Maximum 40 mg/day. IV/IM: 1 mg/kg to 2 mg/kg per dose once daily. Maximum 20 mg/dose. Doses may be increased if needed, but monitor closely.
## Dose Adjustments
* **Renal Impairment:** Dose may need to be increased in patients with renal impairment due to decreased GFR and impaired tubular secretion. However, high doses may be less effective and more ototoxic in severe renal failure. Monitor fluid and electrolyte status closely.
* **Hepatic Impairment:** Use with caution. Cirrhosis patients may have altered pharmacokinetics.
## Contraindications
* Anuria
* Hypersensitivity to furosemide or sulfonamides
## Adverse Effects
* **Common:** Dizziness, lightheadedness, headache, electrolyte imbalances (hypokalemia, hyponatremia, hypochloremia), dehydration, hypotension.
* **Serious:** Ototoxicity (especially with rapid IV administration or high doses), severe allergic reactions, Stevens-Johnson syndrome, aplastic anemia, pancreatitis, rhabdomyolysis.
## Key Drug Interactions
* **Aminoglycosides:** Increased risk of ototoxicity and nephrotoxicity.
* **NSAIDs:** May reduce diuretic and antihypertensive effects.
* **Lithium:** Reduced renal clearance, increasing risk of lithium toxicity.
* **Antihypertensives:** Additive hypotensive effect.
* **Corticosteroids:** Increased risk of hypokalemia.
* **Digoxin:** Increased risk of digoxin toxicity due to furosemide-induced hypokalemia.
## Monitoring
* Electrolytes (sodium, potassium, chloride, magnesium, calcium)
* Renal function (BUN, creatinine)
* Fluid balance (intake and output, weight)
* Blood pressure
* Auditory function (if high doses or risk factors for ototoxicity)
## Clinical Pearls
* Administer oral furosemide in the morning to minimize nocturia.
* IV administration should be slow (over 30-60 minutes) to reduce the risk of ototoxicity.
* Potassium supplementation or potassium-sparing diuretics may be necessary to manage hypokalemia.
* Monitor for signs of dehydration and electrolyte imbalances.
Please verify the information with the most current prescribing information or official drug compendium.
