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Loop DiureticAka: Furosemide, Lasix, Bumetanide, Bumex, Torsemide, Demadex

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  1. Indications
    1. Symptomatically reduce pulmonary and peripheral edema
      1. Renal Insufficiency
      2. Congestive Heart Failure
    2. Emergency Management of Pulmonary Congestion (Lasix)
      1. Left Ventricular Dysfunction (CHF)
  2. Contraindications
    1. Sulfonamide allergy
  3. Mechanism
    1. Potently inhibits reabsorption of sodium and chloride
      1. Action at ascending loop of Henle in glomerulus
    2. Direct Venodilation in Pulmonary edema
      1. Reduces venous return (preload)
      2. Reduces central venous pressure
      3. Synergistic effect with morphine and Nitroglycerin
    3. Reduces Intravascular Volume
      1. Reduces cardiac output
      2. Beware hypotension in Myocardial Infarction
  4. Preparations: Bumetanide (Bumex)
    1. Oral dosing (adults)
      1. Start: 0.5 to 1 mg orally twice daily
      2. Maximum: 10 mg/day
      3. Duration: 4-6 hours
    2. Intravenous dosing (adults)
      1. Start: 1 mg IV/dose (Max: 4-8 mg/dose)
    3. Intravenous Infusion (adults)
      1. Load: 1 mg IV
      2. Rate: 0.5 to 2 mg/hour IV
  5. Preparations: Furosemide (Lasix)
    1. Precautions
      1. Lasix (named for LAst SIX) is only effective for 6 hours
      2. Optimal dosing is given at least twice daily (patient otherwise is sodium avid 18 hours/day)
    2. Oral Dosing (adults)
      1. Start: 20-40 mg PO daily to twice daily
      2. Maximum: 600 mg/day (rare to exceed 400 mg/day)
      3. Duration: 6-8 hours
    3. Intravenous Dosing
      1. Administer slowly over 1-2 minutes
      2. Bolus: 20-40 mg IV (0.5-1.0 mg/kg, max 2 mg/kg)
      3. Infusion: 0.25 to 0.75 mg/kg/hour
      4. Onset: Diuresis starts within 10 minutes
      5. Duration: 6 hours (Peak effect in 30 minutes)
    4. Intravenous Infusion
      1. Load: 40 mg
      2. Rate: 10-40 mg/hour IV
  6. Preparations: Torsemide (Demadex)
    1. Oral Dosing (adults)
      1. Start: 10-20 mg PO daily
      2. Maximum: 200 mg/day
      3. Duration: 12-16 hours
    2. Intravenous Dosing (adults)
      1. Start: 10 mg IV
      2. Maximum: 100-200 mg/day
    3. Intravenous Infusion (adults)
      1. Load: 20 mg
      2. Rate: 5-20 mg/hour
  7. Adverse Effects
    1. Risk of central volume depletion (dehydration)
    2. Hypotension
    3. Electrolyte abnormalities
      1. Metabolic Alkalosis
      2. Hypokalemia
      3. Hypomagnesemia
      4. Hypocalcemia
      5. Hyponatremia
      6. Hyperosmolality
    4. Renal dysfunction
      1. Minimize dosage when starting an ACE Inhibitor
  8. Loop Diuretic Resistance Mechanisms
    1. Renal insufficiency
      1. Renal toxin (e.g. NSAID) decreases GFR
      2. NSAIDs
    2. Decreased Diuretic oral absorption
    3. Structural changes in the kidney
      1. Normal aging
      2. Distal tubular hypertrophy (long term use)
        1. Consider adding a Thiazide Diuretic
        2. Counters distal tubular reabsorption
        3. Significantly boosts Loop Diuretic effect
    4. Increased dietary sodium intake
      1. CHF patient is an avid sodium retainer
      2. Sodium is common in most foods
        1. Chicken Noodle soup = 1200 meq
        2. Milk 122 meq
        3. Big Mac 1010 meq
        4. Canned Spinach 910 meq
  9. Precautions
    1. All loop Diuretics except Torsemide need to be dosed twice daily for effect

Bumetanide (C0006376)

Definition (MSH)A sulfamyl diuretic.
Definition (CSP)3-butylamino-4-phenoxy-5-sulfamoylbenzoic acid.
Definition (NCI)A synthetic butylamino-sulfamoylbenzoic acid derivative, Bumetanide is a loop diuretic that inhibits sodium reabsorption in the ascending limb of the loop of Henle; potassium excretion is increased in a dose-related fashion. Bumetanide is used for edema associated with congestive heart failure, cirrhosis, and nephrotic syndrome. (NCI04)
ConceptsOrganic Chemical (T109) , Pharmacologic Substance (T121)
EnglishBumetanide, BUMETANIDE PREPARATION, Bumethanide
Spanishbumetanida
CreditsDerived from the NIH UMLS (Unified Medical Language System)


Furosemide (C0016860)

Definition (MSH)A benzoic-sulfonamide-furan. It is a diuretic with fast onset and short duration that is used for EDEMA and chronic RENAL INSUFFICIENCY.
Definition (CSP)sulfamyl saluretic and diuretic; has a fast onset and short duration of action and is used in edema and chronic renal insufficiency.
Definition (PDQ)An anthranilic derivative and loop diuretic with antihypertensive effect. Furosemide blocks the Na-K-Cl cotransporter (NKCC) in the luminal membrane of the thick ascending limb of the loop of Henle in the kidney, by binding to the Cl-binding site located in the cotransporter's transmembrane domain, thereby inhibiting reabsorption of sodium, chloride, potassium ions and water. This agent reduces plasma and extracellular fluid volume resulting in decreased blood pressure and cardiac output. Check for "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=39247&idtype=1" active clinical trials or "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=39247&idtype=1&closed=1" closed clinical trials using this agent. ("http://nciterms.nci.nih.gov:80/NCIBrowser/ConceptReport.jsp?dictionary=NCI_Thesaurus&code=C515" NCI Thesaurus)
Definition (NCI)An anthranilic derivative and loop diuretic with antihypertensive effect. Furosemide blocks the Na-K-Cl cotransporter (NKCC) in the luminal membrane of the thick ascending limb of the loop of Henle in the kidney, by binding to the Cl-binding site located in the cotransporter's transmembrane domain, thereby inhibiting reabsorption of sodium, chloride, potassium ions and water. This agent reduces plasma and extracellular fluid volume resulting in decreased blood pressure and cardiac output.
ConceptsOrganic Chemical (T109) , Pharmacologic Substance (T121)
EnglishFRS, Frusemid, Frusemide, Furosemide, FUROSEMIDE PREPARATION, Fursemide
Spanishfrusemida, furosemida
CreditsDerived from the NIH UMLS (Unified Medical Language System)


torsemide (C0076840)

Definition (NCI)An anilinopyridine sulfonylurea, belong to the class called loop diuretics with anti-hypertensive property. Torsemide interferes with the Na+ binding site of the Na-K-Cl symporter in the luminal membrane of the ascending portion of the loop of Henle in the kidney, thereby blocking the reabsorption of sodium and chloride. This results in an increased excretion of sodium, potassium, chloride, and water. Torsemide exerts its antihypertensive effect through the reduction in plasma volume which subsequently results in increased aldosterone production and ultimately in sodium reabsorption to the blood thereby stabilizing blood pressure.
ConceptsOrganic Chemical (T109) , Pharmacologic Substance (T121)
EnglishTorasemide, torsemide, TORSEMIDE PREPARATION
Spanishtorasemida, torsemida
CreditsDerived from the NIH UMLS (Unified Medical Language System)


Demadex (C0243946)

ConceptsOrganic Chemical (T109) , Pharmacologic Substance (T121)
EnglishDemadex
CreditsDerived from the NIH UMLS (Unified Medical Language System)


Lasix (C0699992)

ConceptsOrganic Chemical (T109) , Pharmacologic Substance (T121)
EnglishLasix
CreditsDerived from the NIH UMLS (Unified Medical Language System)


Bumex (C0701009)

ConceptsOrganic Chemical (T109) , Pharmacologic Substance (T121)
EnglishBumetanide Roche Brand, Bumex, Roche Brand of Bumetanide
CreditsDerived from the NIH UMLS (Unified Medical Language System)



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