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Generic Name: Furosemide
Class: Loop Diuretics
VA Class: CV702
CAS Number: 54-31-9

Warning(s)

  • Furosemide is a potent diuretic that given in excessive amounts may induce a profound diuresis with water and electrolyte depletion.133 e Careful medical supervision is required; dosage selection and titration should be adjusted to the individual patient’s needs.133 e (See Dosage and Administration.)

Introduction

A sulfonamide, loop-type diuretic and antihypertensive agent.133 e

Uses for Lasix

Edema

Management of edema associated with CHF, hepatic cirrhosis, and renal disease (e.g., nephrotic syndrome).133 e

Considered a diuretic of choice for most patients with CHF.131

IV management of acute pulmonary edema (in combination with oxygen and a cardiac glycoside).150

Slideshow: View Frightful (But Dead Serious) Drug Side Effects

Hypertension

Management of hypertension (alone or in combination with other classes of antihypertensive agents).100 101 109 124 127 133 144

One of several preferred initial therapies in hypertensive patients with CHF or renal disease.100 101 109 124 127 144

Can be used as monotherapy for initial management of uncomplicated hypertension; however, thiazide diuretics are preferred by JNC 7.100 101 124 127 142 143 144

Lasix Dosage and Administration

General

Edema

  • Careful etiologic diagnosis should precede the use of any diuretic.e

  • Hospitalization of the patient during initiation of therapy is advisable, especially for patients with hepatic cirrhosis and ascites or chronic renal failure.133 e

  • Most experts state that all patients with symptomatic CHF who have evidence for, or a prior history of, fluid retention generally should receive diuretic therapy in conjunction with moderate sodium restriction (≤3 g of sodium daily), an ACE inhibitor, and usually a β-blocker, with or without a cardiac glycoside.131

  • In prolonged diuretic therapy, intermittent use of the drug (e.g., on 2–4 consecutive days each week) may be advisable.e

Hypertension

  • Monitor BP carefully, especially during initial therapy.133

  • If added to regimen of a patient receiving another antihypertensive agent, reduce dosage of preexisting therapy by at least 50% initially to avoid severe hypotension; additional dosage adjustment may be required.133

Administration

Administer orally, IV, or IM.133 150

Oral Administration

Administer orally once (preferably in the morning)e or twice daily .133

For ease of administration and maximum dosage flexibility in children, consider use of oral solution preparation.151

IV Administration

For solution and drug compatibility information, see Compatibility under Stability.

IV administration may be used in emergency clinical circumstances when a rapid onset of diuresis is desired, or in patients unable to take oral medication or those with impaired GI absorption; replace with oral therapy as soon as possible.133 150 e

Consider the potential risks, when using large parenteral doses; monitor patient closely.105 107

Dilution

For IV infusion, dilute in 5% dextrose, 0.9% sodium chloride, or lactated Ringer’s injection and adjust pH to >5.5.150 e

Whenever possible, use vials instead of ampuls to prepare large doses to prevent large quantities of glass particles from entering the solutions.e If ampuls must be used, consider filtering through a sterile membrane filter before use to remove any particles that may be present.e

Rate of Administration

For direct IV injection, administer slowly over a period of 1–2 minutes.150 e

If high-dose parenteral furosemide therapy is necessary, the manufacturer recommends that the drug be administered as a controlled infusion at a rate not exceeding 4 mg/minute in adults.150 e

Dosage

Individualize dosage according to patient’s requirements and response; titrate dosage to gain maximum therapeutic effect while using the lowest possible effective dosage.e (See Boxed Warning.)

Pediatric Patients

Edema
Oral

2 mg/kg administered as a single dose.103 104 105 107 108 133 If necessary, increase in increments of 1 or 2 mg/kg every 6–8 hours103 104 105 107 108 to a maximum of 6 mg/kg.103 133 Generally not necessary to exceed individual doses of 4 mg/kg or a dosing frequency of once or twice daily.104 Use minimum effective dosage for maintenance therapy.133

IV or IM

1 mg/kg administered as a single IM or IV injection.103 104 105 106 107 108 150 If necessary for resistant forms of edema, the initial dose may be increased by 1 mg/kg103 104 105 108 no more often than every 2 hours until the desired effect has been obtained or up to a maximum dosage of 6 mg/kg.103 Adequate response usually is obtained with individual parenteral doses of 1 mg/kg.104 105 107 108

Acute Pulmonary Edema
IV or IM

1 mg/kg administered as a single IM or IV injection.103 104 105 106 107 108 150 If necessary for resistant forms of edema, the initial dose may be increased by 1 mg/kg103 104 105 108 no more often than every 2 hours until the desired effect has been obtained or up to a maximum dosage of 6 mg/kg.103 Adequate response generally obtained with 1 mg/kg.104 105 107 108

Hypertension
Oral

Initially, 0.5–2 mg/kg given once or twice daily.149 Increase as necessary up to a maximum of 6 mg/kg daily.149

Adults

Edema
Oral

20–80 mg given as a single dose, preferably in the morning.133 e If needed, repeat same dose 6–8 hours later or increase dose by 20- to 40-mg increments and give no sooner than 6–8 hours after last dose until desired diuretic response (including weight loss) is obtained.133 e May titrate carefully up to 600 mg daily in severe cases.133

The effective dose may be given once or twice daily thereafter, or, in some cases, by intermittent administration on 2–4 consecutive days each week.133 e Dosage may be reduced for maintenance therapy.e

IV or IM

20–40 mg given as a single IM or IV injection.150 e If needed, repeat same dose 2 hours later or increase dose by 20-mg increments and give no sooner than every 2 hours until the desired diuretic response is obtained.150 Effective dosages may then be given once or twice daily.150

Acute Pulmonary Edema
IV

40 mg given as a single IV injection.150 If needed, an 80-mg dose may be given 1 hour after the initial dose.150

Hypertension
Oral

40 mg twice daily.133 If desired BP not attained, consider adding other antihypertensive agents.133

Usual dosage recommended by JNC 7: 10–40 mg twice daily.127 144

Prescribing Limits

Pediatric Patients

Edema
Oral

Maximum of 6 mg/kg.103 133

IV or IM

Maximum of 6 mg/kg in infants and children; do not exceed 1 mg/kg daily in premature infants.150

Hypertension
Oral

Maximum 6 mg/kg daily.149

Adults

Edema
Oral

Maximum of 600 mg daily.133

Special Populations

Renal Impairment

Higher doses may be required for patients with acute or chronic renal failure.e

Hypertension

Higher doses may be required for patients with acute or chronic renal failure.e

Oral

Use of ≥3 antihypertensive agents usually is required to achieve a target BP <130/80 mm Hg.144

Cautions for Lasix

Contraindications

  • Anuria.133

  • Known hypersensitivity to furosemide or any ingredient in the formulation.133

Warnings/Precautions

Warnings

Hepatic Effects

Sudden alterations of electrolyte balance in patients with cirrhosis may precipitate hepatic coma; use with caution in patients with hepatic cirrhosis and ascites.133

Do not initiate therapy in patients with hepatic coma or electrolyte depletion until the basic condition is improved.133 Therapy in such patients is best initiated in the hospital with careful monitoring of clinical status and electrolyte balance.133

Renal Effects

If increasing azotemia and oliguria occur during treatment of severe progressive renal disease, discontinue the drug.133 150

Sensitivity Reactions

Anaphylaxis

Anaphylaxis (e.g., urticaria, angioedema, hypotension) within 5 minutes after IV administration reported.102

Systemic Lupus Erythematosus

Possible exacerbation or activation of systemic lupus erythematosus.133 150

Sulfonamide Sensitivity

Patients sensitive to sulfonamides may show allergic reactions to furosemide.e

Photosensitivity

Photosensitivity may occur.133

Major Toxicities

Ototoxicity

Risk of tinnitus, reversible or permanent hearing impairment increased following IV or IM administration, especially at high dosages,133 e after too-rapid administration,133 in patients with severely impaired renal function, and/or in patients receiving other ototoxic drugs (e.g., aminoglycosides).133 e (See Specific Drugs under Interactions.)

If high-dose IV therapy is indicated, administer by slow IV infusion (e.g., at a rate not exceeding 4 mg/minute in adults).133 150

General Precautions

Fluid, Electrolyte, and Cardiovascular Effects

Excessive diuresis may cause dehydration and blood volume reduction with circulatory collapse and possibly vascular thrombosis and embolism, particularly in elderly patients.133 (See Boxed Warning.)

Risk of orthostatic hypotension, especially with brisk diuresis.133 150 151 May be aggravated by concomitant use with alcohol, barbiturates, or narcotics.133 151 e

Risk of hypokalemia, especially with brisk diuresis, inadequate oral electrolyte intake, when cirrhosis is present, or during concomitant use of corticosteroids or ACTH.133 150 Concomitant therapy with digitalis may exaggerate metabolic effects of hypokalemia, especially myocardial effects.133 150

Observe carefully for manifestations of fluid and electrolyte depletion (e.g., dryness of mouth, thirst, weakness, lethargy, drowsiness, restlessness, muscle pains or cramps, muscular fatigue, hypotension, oliguria, tachycardia, arrhythmia, nausea, vomiting).133

Endocrine Effects

Possible increased blood glucose and alterations in glucose tolerance tests (with abnormalities of the fasting and 2-hour postprandial sugar); precipitation of diabetes mellitus rarely reported.133 150 Monitor urine and blood glucose concentrations periodically in patients with diabetes and those suspected of latent diabetes.e

Possible hyperuricemia and precipitation of gout;133 150 use with caution in patients with a history of gout or elevated serum uric acid concentrations.e

Patient Monitoring

Monitor regularly for the possible occurrence of blood dyscrasias, liver or kidney damage, or other idiosyncratic reactions.133 150

Serum electrolytes (particularly potassium), CO2, creatinine and BUN should be determined frequently during the first few months of therapy and periodically thereafter.133 150

Elective Surgery

Discontinue therapy 1 week (oral furosemide) or 2 days (parenteral furosemide) before elective surgery.e

Specific Populations

Pregnancy

Category C.133

Lactation

Distributed into milk.133 Use with caution.133

Pediatric Use

Risk of persistent patent ductus arteriosus (PDA) may be increased in premature neonates with respiratory distress syndrome (RDS) who receive furosemide during the first weeks of life.103 e

Do not exceed dosage of 1 mg/kg per 24 hours in premature neonates with <31 weeks’ postconception age (gestational age at birth plus postnatal age); risk of potentially toxic furosemide plasma concentrations with higher dosages.150

Renal calcification reported in severely premature infants treated with IV furosemide for edema due to PDA and hyaline membrane disease; concomitant chlorothiazide therapy may decrease hypercalciuria and dissolve some calculi.150

Hearing loss reported in neonates; possibly secondary to renal immaturity.103 125 126 150

Oral solutions contain sorbitol; high dosages may cause diarrhea in children.e

Hepatic Impairment

Use with caution.133 e

Renal Impairment

Use with caution.133 e

Common Adverse Effects

Orthostatic hypotension, dizziness, electrolyte imbalance (hyponatremia, hypokalemia, hypochloremia) tinnitus, photosensitivity.133 e

Interactions for Lasix

Specific Drugs

Drug

Interaction

Comments

Alcohol

May aggravate orthostatic hypotension133 151 e

Anticonvulsant agents (e.g., phenytoin sodium, phenobarbital)

Possible reduced diuretic effecte

Antidiabetic agents (e.g., insulin, oral agents)

Possible antagonism of hypoglycemic effect as result of hypokalemia133

Observe for possible decreased diabetic control; correct potassium deficit and/or adjust dosage of antidiabetic agente

Antihypertensive agents

Additive antihypertensive effect; orthostatic hypotension may occur133

Reduce dosage of both drugse

Concomitant therapy generally used to therapeutic advantagee

Barbiturates

May aggravate orthostatic hypotension133 151 e

Cardiac glycoside (e.g., digoxin)

Possible electrolyte disturbances (e.g., hypokalemia, hypomagnesemia), increased risk of digitalis toxicity, and/or fatal cardiac arrhythmias e

Monitor electrolytes; correct hypokalemia e

Chloral hydrate

Possible reaction characterized by diaphoresis, flushes, hypertension, and uneasiness in patients with acute MI and CHFe

Consider alternate hypnotic drug (e.g., a benzodiazepine) in patients who require IV furosemidee

Diuretics, loop (e.g., bumetanide, ethacrynic acid, torsemide)

Share similar diuretic mechanisms e

No therapeutic rationale for concomitant usee

Diuretics, potassium- sparing (e.g., amiloride, spironolactone, triamterene)

Possible reduction in potassium loss 133

May be used to therapeutic advantage133

Diuretics, thiazides

Additive diuretic effecte

Use reduced dosage of furosemide when added to existing diuretic regimene

Drugs that cause potassium loss (e.g., corticosteroids, corticotropin, amphotericin B)

Additive hypokalemic effects133 e

Monitor electrolytes; correct hypokalemia 133 e

Indomethacin

Possible decreased diuretic and natriuretic effect133

Monitor closely to determine if desired diuretic and/or hypotensive effect is obtained133

Lithium

Reduced renal clearance of lithium and increased risk of lithium toxicity 133

Avoid concomitant use;133 e if concomitant therapy is necessary, monitor for lithium toxicitye

Narcotics

May aggravate orthostatic hypotension133 151 e

Neuromuscular blocking agents, nondepolarizing (e.g., atracurium besylate, tubocurarine chloride)

Potential for prolonged neuromuscular blockadee

Norepinephrine

Decreased arterial responsive to norepinephrine133

Norepinephrine may still be used effectively133

Ototoxic drugs (e.g., aminoglycoside antibiotics)

Possible additive ototoxic effect, especially in patients with impaired renal function133

Avoid concomitant use except in life-threatening situations133

Salicylates (e.g., aspirin, NSAIAs)

Possible transient reductions in Clcr in patient with chronic renal insufficiencye

Possible weight gain and increased Scr, serum potassium concentrations, and BUN (NSAIAs)133

Monitor for toxicity133

Succinylcholine

May potentiate action of succinylcholine133

Sucralfate

Possible reduced natriuretic and antihypertensive effects133

Do not administer simultaneously; separate administration by ≥2 hours133

Observe closely for desired diuretic and/or antihypertensive effect133

Uricosuric drugs (probenecid, sulfinpyrazone)

Possible antagonism of uricosuric effectse

Monitor serum uric acid concentrationse

Lasix Pharmacokinetics

Absorption

Bioavailability

Mean oral bioavailability of furosemide from commercially available tablets and oral solution is 64% and 60%, respectively.133

Commercially available tablets and oral solution are bioequivalent.133

Onset

Following oral administration, onset of diuresis occurs within 30 minutes to 1 hour; maximal effect after 1–2 hours.133 e

Following IV administration, diuresis occurs within 5 minutes and peaks within 20–60 minutes.150 e

Onset of diuresis after IM administration occurs somewhat later than after IV administration.150

Maximum hypotensive effect may not be apparent until after several days of therapy.e

Duration

Diuretic effect persists 6–8 hours following oral administration and approximately 2 hours following IV administration.133 150 e

Food

Food does not appear to affect diuretic effect.e

Special Populations

In patients with severely impaired renal function, the diuretic response may be prolonged.e

Distribution

Extent

Crosses the placenta and is distributed into milk.e

Plasma Protein Binding

Approximately 95% bound to plasma proteins (mainly albumin) in both normal and azotemic patients.133 e

Elimination

Metabolism

Metabolized in the liver to the defurfurylated derivative, 4-chloro-5-sulfamoylanthranilic acid.e

Elimination Route

Rapidly excreted in urine by glomerular filtration and by secretion from the proximal tubule.e

Approximately 50% of an oral dose and 80% of an IV or IM dose are excreted in urine within 24 hours; 69–97% of these amounts is excreted in the first 4 hours.150 e The remainder of the drug is eliminated by nonrenal mechanisms including degradation in the liver and excretion of unchanged drug in the feces.e

Half-life

Biphasic;e terminal half-life is approximately 2 hours.133

Special Populations

Hepatic or renal impairment prolongs the elimination half-life of the drug.e

In patients with marked renal impairment without liver disease, nonrenal clearance is increased to the extent that up to 98% of the drug is cleared within 24 hours.e

Not removed by hemodialysis.133

Stability

Storage

Oral

Solution or Tablets

Tight, light resistant containers at 15–30°C.133 151

Parenteral

Injection

15–30°C; protect from light.150 Discard unused portion.150

Compatibility

For information on systemic interactions resulting from concomitant use, see Interactions.

Parenteral

Do not mix with strongly acidic solutions (i.e., pH < 5.5), such as those containing ascorbic acid, amrinone, ciprofloxacin, labetalol, tetracycline, milrinone, epinephrine, or norepinephrine, because furosemide may be precipitated.150 e

Solution Compatibilitya

Compatible

Alcohol 5% and dextrose 5%

Amino acids 4.25%, dextrose 25%

Dextrose 5% in Ringer’s injection, lactated

Dextrose 5% in sodium chloride 0.9%

Dextrose 5, 10, or 20% in water

Invert sugar 10% in Electrolyte #1

Mannitol 20%

Ringer’s injection, lactated

Sodium chloride 0.9%

Sodium lactate (1/6) M

Incompatible

Fructose 10% in water

Invert sugar 10% in Electrolyte #2

Drug Compatibility
Admixture Compatibilitya

Compatible

Amikacin sulfate

Aminophylline

Ampicillin sodium

Atropine sulfate

Bumetanide

Calcium gluconate

Cefuroxime sodium

Cimetidine HCl

Dexamethasone sodium phosphate

Diamorphine HCl

Digoxin

Epinephrine HCl

Heparin sodium

Hydrocortisone sodium succinate

Isosorbide dinitrate

Kanamycin sulfate

Lidocaine HCl

Midazolam HCl

Meropenem

Morphine sulfate

Nitroglycerin

Penicillin G

Potassium chloride

Ranitidine HCl

Scopolamine butylbromide

Sodium bicarbonate

Sulphadimidine

Theophylline

Tobramycin sulfate

Incompatible

Buprenorphine HCl

Chlorpromazine HCl

Diazepam

Dobutamine HCl

Erythromycin lactobionate

Isoproterenol HCl

Meperidine HCl

Metoclopramide HCl

Papaveretum

Prochlorperazine edisylate

Promethazine HCl

Variable

Amiodarone HCl

Gentamicin sulfate

Hydrocortisone sodium succinate

Verapamil HCl

Y-Site Compatibilitya

Compatible

Allopurinol sodium

Amifostine

Amikacin sulfate

Amphotericin B cholesteryl sulfate complex

Aztreonam

Bivalirudin

Bleomycin sulfate

Cefepime HCl

Ceftazidime

Cisplatin

Cladribine

Cyclophosphamide

Cytarabine

Dexmedetomidine HCl

Docetaxel

Doxorubicin HCl liposome injection

Epinephrine HCl

Etoposide phosphate

Fentanyl citrate

Fludarabine phosphate

Fluorouracil

Foscarnet sodium

Granisetron HCl

Heparin sodium

Hetastarch in lactated electrolyte injection (Hextend)

Hydrocortisone sodium succinate

Hydromorphone HCl

Indomethacin sodium trihydrate

Kanamycin sulfate

Leucovorin calcium

Linezolid

Lorazepam

Melphalan HCl

Meropenem

Methotrexate sodium

Mitomycin

Nitroglycerin

Norepinephrine bitartrate

Paclitaxel

Piperacillin sodium–tazobactam sodium

Potassium chloride

Propofol

Ranitidine HCl

Remifentanil HCl

Sargramostim

Sodium nitroprusside

Tacrolimus

Tirofiban HCl

Teniposide

Thiotepa

Tirofiban

Tobramycin sulfate

Vitamin B complex with C

Incompatible

Amsacrine

Azithromycin

Chlorpromazine HCl

Ciprofloxacin

Clarithromycin

Diltiazem HCl

Droperidol

Esmolol HCl

Fenoldopam mesylate

Filgrastim

Fluconazole

Gatifloxacin

Gemcitabine HCl

Gentamicin sulfate

Hydralazine HCl

Idarubicin HCl

Levofloxacin

Metoclopramide HCl

Midazolam HCl

Milrinone lactate

Nicardipine HCl

Ondansetron HCl

Quinidine gluconate

Thiopental sodium

Vecuronium bromide

Vinblastine sulfate

Vincristine sulfate

Vinorelbine tartrate

Variable

Amiodarone HCl

Dobutamine HCl

Dopamine HCl

Doxorubicin HCl

Famotidine

Labetalol HCl

Meperidine HCl

Morphine sulfate

Actions

  • Inhibits primarily the absorption of sodium and chloride not only in the proximal and distal tubules but also in the ascending limb of the loop of Henle.133 e Does not inhibit carbonic anhydrase and is not an aldosterone antagonist.e

  • Mechanism of hypotensive effect not definitively determined but presumed to result from decreased plasma volume.e

  • Induces greater diuresis and electrolyte loss than with thiazides or most other diuretics except ethacrynic acid.e

  • Possesses some renal vasodilator effect; renal vascular resistance decreases and renal blood flow increases following administration.e

Advice to Patients

  • Risks associated with excessive fluid loss or electrolyte imbalance.133

  • Potential for postural hypotension; importance of rising slowly from a seated position.133

  • Importance of discussing dietary measures and supplementation to prevent or correct hypokalemia.133

  • Importance of informing patients with diabetes mellitus that blood glucose and urine glucose concentrations may increase.133 e

  • Importance of informing patients of possible photosensitivity.133 e

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs (e.g., appetite suppressants, cold remedies) as well as any concomitant illnesses.133 e

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.133 e

  • Importance of informing patients of other important precautionary information.133 e (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Furosemide

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Solution

40 mg/5 mL*

Furosemide Solution (with alcohol 0.2% and sorbitol)

Roxane

10 mg/mL*

Furosemide Solution

Morton Grove, Roxane

Tablets

20 mg*

Furosemide Tablets

IVAX, Mylan, Qualitest, Roxane, Sandoz, UDL

Lasix

Sanofi-Aventis

40 mg*

Furosemide Tablets

IVAX, Mylan, Qualitest, Roxane, Sandoz, UDL

Lasix (scored)

Sanofi-Aventis

80 mg*

Furosemide Tablets

Mylan, Qualitest, Roxane, Sandoz, UDL

Lasix

Sanofi-Aventis

Parenteral

Injection

10 mg/mL*

Furosemide Injection

American Pharmaceutical Partners, American Regent, Hospira, IMS

Comparative Pricing

This pricing information is subject to change at the sole discretion of DS Pharmacy. This pricing information was updated 02/2014. Actual costs to patients will vary depending on the use of specific retail or mail-order locations and health insurance copays.

Furosemide 10MG/ML Solution (ROXANE): 60/$17.99 or 120/$25.98

Furosemide 20MG Tablets (SANDOZ): 100/$14.99 or 200/$19.97

Furosemide 40MG Tablets (SANDOZ): 100/$17.99 or 200/$26.98

Furosemide 80MG Tablets (SANDOZ): 30/$12.99 or 60/$15.98

Lasix 20MG Tablets (SANOFI-AVENTIS U.S.): 30/$26.99 or 90/$51.97

Lasix 40MG Tablets (SANOFI-AVENTIS U.S.): 30/$26.99 or 90/$57.97

Lasix 80MG Tablets (SANOFI-AVENTIS U.S.): 30/$32.99 or 90/$76.97

AHFS DI Essentials. © Copyright, 2004-2014, Selected Revisions April 1, 2010. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.

References

Only references cited for selected revisions after 1984 are available electronically.

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