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# Furosemide
## Overview
Furosemide is a potent 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 manage hypertension, usually in combination with other antihypertensives.
## Primary Indications
* Edema due to heart failure, liver cirrhosis, and renal disease
* Hypertension
## Adult Dosing
* **Edema:**
* Oral: Initial dose of 20-80 mg once daily. May increase by 20-40 mg every 6-8 hours as needed. Usual maintenance dose is 40 mg once or twice daily. Maximum daily dose is 600 mg.
* Intravenous (IV) or Intramuscular (IM): Initial dose of 20-40 mg once daily. May increase by 20 mg every 2 hours as needed. Usual maintenance dose is 40 mg once or twice daily. Maximum daily dose is 600 mg.
* For patients already receiving oral furosemide, the initial IV/IM dose may be 1-2 times the daily oral dose.
* **Hypertension:**
* Oral: Initial dose of 40 mg twice daily. May be adjusted to 80-120 mg per day in divided doses. Not recommended as a first-line agent for hypertension.
## Pediatric Dosing
* **Edema:**
* Oral: 1-2 mg/kg/dose once daily, not to exceed 40 mg/dose. If inadequate response, dose may be increased by 1-2 mg/kg/dose every 6-8 hours. Maximum daily dose is 6 mg/kg/day.
* IV/IM: 1 mg/kg/dose once daily, not to exceed 20 mg/dose. If inadequate response, dose may be increased by 1 mg/kg/dose every 2 hours. Maximum daily dose is 6 mg/kg/day.
## Dose Adjustments
* **Renal Impairment:** Dose may need to be adjusted. In patients with significant renal impairment, higher doses may be required. Monitor closely for electrolyte imbalances and volume depletion.
* **Hepatic Impairment:** Dose may need to be adjusted. Monitor closely for electrolyte imbalances and volume depletion.
## Contraindications
* Anuria
* History of hypersensitivity to furosemide or sulfonamides
## Adverse Effects
* **Common:** Dizziness, lightheadedness, electrolyte imbalances (hypokalemia, hyponatremia, hypochloremia, hypomagnesemia, hypocalcemia), dehydration, hyperuricemia, hyperglycemia.
* **Serious:** Ototoxicity (especially with rapid IV administration or high doses), severe hypotension, Stevens-Johnson syndrome, aplastic anemia.
## Key Drug Interactions
* **Aminoglycosides:** Increased risk of ototoxicity and nephrotoxicity.
* **ACE inhibitors/ARBs:** Increased risk of hypotension and hyperkalemia.
* **NSAIDs:** May reduce diuretic and antihypertensive effect, and increase risk of renal impairment.
* **Lithium:** Reduced renal clearance of lithium, increasing risk of lithium toxicity.
* **Digoxin:** Increased risk of digoxin toxicity due to furosemide-induced hypokalemia.
* **Corticosteroids:** Increased risk of hypokalemia.
## Monitoring
* Electrolytes (sodium, potassium, chloride, magnesium, calcium)
* Renal function (BUN, creatinine)
* Blood pressure
* Urine output
* Blood glucose (especially in diabetic patients)
* Serum uric acid
## Clinical Pearls
* Administer oral furosemide preferably on an empty stomach. If gastric irritation occurs, administer with food.
* Administer IV furosemide slowly (e.g., over 60 minutes) to minimize ototoxicity. Rapid IV injection in doses >80 mg can cause transient deafness.
* For patients with heart failure and edema, dose may be adjusted based on daily weight changes.
* Hypokalemia is a common and significant adverse effect; consider potassium supplementation or potassium-sparing diuretics if indicated.
* Monitor for signs of dehydration and electrolyte imbalance, especially in elderly patients or those with impaired renal function.
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*This information is intended for healthcare professionals. It is essential to consult the current prescribing information and relevant clinical guidelines for complete details and to make informed treatment decisions. Dosing may vary based on individual patient factors and local protocols.*
