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# Furosemide
## Overview
Furosemide is a loop diuretic used to treat edema associated with heart failure, liver disease, and renal disease, including in patients with nephrotic syndrome. It is also used to treat hypertension, usually in combination with other antihypertensive agents.
## Primary Indications
* Edema associated with congestive heart failure, cirrhosis, and renal disease.
* Hypertension.
## Adult Dosing
* **Edema:** The usual initial dose is 20-80 mg orally once daily. Doses can be increased by 20-40 mg every 6-8 hours as needed. For maintenance, doses may be given once or twice daily. Intermittent dosing (e.g., every other day or for 4 days a week) may be effective and reduce electrolyte disturbances.
* **Hypertension:** The usual initial dose is 40 mg orally twice daily. It is typically used in combination with other antihypertensives.
* **Maximum Oral Dose:** Generally considered 600 mg daily, though higher doses have been used in specific, supervised clinical settings for severe edema.
## Pediatric Dosing
* **Edema:**
* **Oral:** 1-4 mg/kg/day divided into 1-4 doses. The maximum recommended daily dose is 6 mg/kg.
* **IV/IM:** 1 mg/kg/dose. Maximum of 20 mg per dose for premature infants, and 40 mg per dose for term infants and children. May be repeated every 6-12 hours as needed. For severe edema, higher doses may be administered under close medical supervision.
## Dose Adjustments
* **Renal Impairment:** Dosage may need to be increased in patients with renal impairment due to decreased GFR and impaired tubular secretion. Careful titration and monitoring are essential.
* **Hepatic Impairment:** Use with caution; dosage may need to be adjusted.
## Contraindications
* Anuria.
* Known hypersensitivity to furosemide or its sulfonamide components.
* Electrolyte depletion (e.g., hypokalemia, hyponatremia).
* Hepatic coma or severe electrolyte-depleted states.
## Adverse Effects
* **Common:** Dizziness, lightheadedness, muscle cramps, weakness, orthostatic hypotension, headache.
* **Serious:** Severe electrolyte abnormalities (hypokalemia, hyponatremia, hypochloremia, hypomagnesemia, hypocalcemia), dehydration, azotemia, ototoxicity (especially with rapid IV administration or in renal impairment), hyperglycemia, hyperuricemia.
* **Allergic Reactions:** Rash, pruritus, Stevens-Johnson syndrome, toxic epidermal necrolysis, eosinophilia, pancreatitis.
## Key Drug Interactions
* **Aminoglycosides and other ototoxic drugs:** Increased risk of ototoxicity.
* **NSAIDs:** May reduce the diuretic and antihypertensive effects of furosemide and increase the risk of nephrotoxicity.
* **Lithium:** Furosemide can decrease renal clearance of lithium, increasing the risk of lithium toxicity.
* **Antihypertensives:** Additive hypotensive effect.
* **Corticosteroids:** Increased risk of hypokalemia.
* **Digoxin:** Increased risk of digoxin toxicity due to furosemide-induced hypokalemia.
* **Sucralfate:** May decrease the absorption of furosemide; administer at least 2 hours apart.
## Monitoring
* Electrolytes (sodium, potassium, chloride, magnesium, calcium), BUN, creatinine, urine output, blood pressure, and weight.
* For patients with diabetes, monitor blood glucose.
* For patients receiving high doses or IV furosemide, monitor auditory function and renal function closely.
## Clinical Pearls
* Furosemide is a potent diuretic; titrate dose carefully to avoid excessive fluid and electrolyte loss.
* Administer oral furosemide at least 2 hours before or 6 hours after sucralfate.
* Rapid IV administration can lead to ototoxicity and hypotension. Slow IV infusion is preferred.
* Patients may develop tolerance to the diuretic effect with chronic use, potentially requiring dose escalation.
* Advise patients to take furosemide early in the day to minimize nocturia and sleep disturbances.
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*This information is intended for healthcare professionals. Always consult the current prescribing information and relevant guidelines before making clinical decisions. Dosing may vary based on individual patient factors and local protocols.*
