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# Furosemide
## Overview
Furosemide is a potent 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, Nephrotic Syndrome)
* Hypertension
## Adult Dosing
**Edema:**
* **Oral:** Initially 20-80 mg once daily. The dose may be increased by 20-40 mg every 6-8 hours until desired diuresis is achieved. Subsequent doses are based on response. The usual maintenance dose is 20-80 mg daily. Doses as high as 600 mg/day have been used in severe cases.
* **Intravenous (IV) / Intramuscular (IM):** Initially 20-40 mg once daily. The dose may be increased by 20 mg every 2 hours until desired diuresis is achieved. Subsequent doses are based on response. The usual maintenance dose is 20-40 mg daily. For acute pulmonary edema, administer 40 mg IV. If inadequate response after 2 hours, a subsequent dose of 80 mg IV may be given.
**Hypertension:**
* **Oral:** Initially 40 mg twice daily. Doses may be adjusted based on response. As a sole agent, the maximum dose is generally 80 mg/day. When used in combination, doses may be higher.
## Pediatric Dosing
**Edema:**
* **Oral:** 1-2 mg/kg/dose once daily. If inadequate response, increase dose by 1-2 mg/kg/dose every 6-8 hours. Maximum single dose: 6 mg/kg.
* **IV/IM:** 1 mg/kg/dose once daily. If inadequate response, increase dose by 1 mg/kg/dose every 2 hours. Maximum single dose: 6 mg/kg.
**Note:** Dosing in neonates may require lower doses and more frequent monitoring due to immature renal function.
## Dose Adjustments
* **Renal Impairment:** Patients with severe renal impairment may require lower doses. In patients with ascites and ascites/edema due to cirrhosis, the oral dose should not exceed 40 mg/day.
* **Hepatic Impairment:** Use with caution. Dose reduction may be necessary.
## Contraindications
* Anuria
* Hypersensitivity to furosemide or sulfonamides
## Adverse Effects
* **Electrolyte imbalances:** Hypokalemia, hyponatremia, hypochloremia, metabolic alkalosis, hypomagnesemia, hypocalcemia.
* **Dehydration:** Dizziness, lightheadedness.
* **Ototoxicity:** Tinnitus, hearing impairment (especially with rapid IV administration or high doses).
* **Gastrointestinal:** Nausea, vomiting, diarrhea, constipation.
* **Other:** Hyperuricemia, hyperglycemia, rash, photosensitivity.
## Key Drug Interactions
* **Aminoglycosides:** Increased risk of ototoxicity and nephrotoxicity.
* **Antihypertensives:** Additive hypotensive effect.
* **Digoxin:** Increased risk of digoxin toxicity due to furosemide-induced hypokalemia.
* **NSAIDs:** May reduce diuretic and antihypertensive effect.
* **Potassium-sparing diuretics:** May offset potassium loss, but monitor for hyperkalemia.
## Monitoring
* Electrolytes (serum potassium, sodium, chloride, magnesium, calcium)
* Renal function (BUN, creatinine)
* Fluid balance (intake and output)
* Blood pressure
* Hearing (especially with high doses or rapid IV infusion)
* Blood glucose (in diabetic patients)
* Uric acid
## Clinical Pearls
* Administer oral furosemide with food or milk to minimize GI upset.
* IV administration should be slow (over 30-60 minutes) to reduce the risk of ototoxicity. Avoid rapid bolus injection.
* The dose and frequency of administration should be individualized based on patient response and degree of diuresis.
* Monitor for signs of dehydration and electrolyte imbalances closely.
* May cause photosensitivity; advise patients to use sun protection.
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*Disclaimer: This information is intended for healthcare professionals. Always consult the official prescribing information and current clinical guidelines for complete details before making treatment decisions.*
