I. 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)

II. Contraindications

III. 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

IV. 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

V. 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

VI. 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

VII. 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

VIII. 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

IX. Precautions

  1. All Loop Diuretics except Torsemide need to be dosed twice daily for effect
  2. Loop Diuretics are associated with significant electrolyte abnormalities and volume depletion (FDA black box warning)

Images: Related links to external sites (from Google)

Cost: Medications

FUROSEMIDE (on 2/19/2015 at Target.com)
FUROSEMIDE 20 MG Tablet #90 for $10.00 $0.11 each
FUROSEMIDE 40 MG Tablet #90 for $10.00 $0.11 each
FUROSEMIDE 80 MG Tablet #90 for $10.00 $0.11 each
furosemide (on 1/21/2015 at Medicaid.Gov Survey of pharmacy drug pricing)
FUROSEMIDE 10 MG/ML SOLUTION Generic $0.10 per ml
FUROSEMIDE 20 MG TABLET Generic $0.01 each
FUROSEMIDE 40 MG TABLET Generic $0.01 each
FUROSEMIDE 40 MG/4 ML VIAL Generic $0.39 per ml
FUROSEMIDE 80 MG TABLET Generic $0.03 each
lasix (on 8/20/2014 at Medicaid.Gov Survey of pharmacy drug pricing)
LASIX 20 MG TABLET Generic $0.01 each
LASIX 40 MG TABLET Generic $0.01 each
LASIX 80 MG TABLET Generic $0.03 each
bumetanide (on 1/21/2015 at Medicaid.Gov Survey of pharmacy drug pricing)
BUMETANIDE 0.5 MG TABLET Generic $0.60 each
BUMETANIDE 1 MG TABLET Generic $0.56 each
BUMETANIDE 2 MG TABLET Generic $1.02 each
torsemide (on 1/21/2015 at Medicaid.Gov Survey of pharmacy drug pricing)
TORSEMIDE 10 MG TABLET Generic $0.09 each
TORSEMIDE 100 MG TABLET Generic $0.39 each
TORSEMIDE 20 MG TABLET Generic $0.11 each
TORSEMIDE 5 MG TABLET Generic $0.09 each

Ontology: Bumetanide (C0006376)

Definition (NCI) A potent sulfamoylanthranilic acid derivative belonging to the class of loop diuretics. In the brain, bumetanide may prevent seizures in neonates by blocking the bumetanide-sensitive sodium-potassium-chloride cotransporter (NKCC1), thereby inhibiting chloride uptake thus, decreasing the internal chloride concentration in neurons and may block the excitatory effect of GABA in neonates.
Definition (CSP) 3-butylamino-4-phenoxy-5-sulfamoylbenzoic acid.
Definition (MSH) A sulfamyl diuretic.
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D002034
SnomedCT 387498005, 86647004
LNC LP16052-0, MTHU006833
English Bumetanide, Bumethanide, Benzoic acid, 3-(aminosulfonyl)-5-(butylamino)-4-phenoxy-, bumetanide, bumetanide (medication), BUMETANIDE, Bumetanide [Chemical/Ingredient], Bumetanide (product), Bumetanide (substance)
Swedish Bumetanid
Czech bumetanid
Finnish Bumetaniidi
Russian BUMETANID, БУМЕТАНИД
Japanese ブメタニド
Polish Bumetanid
Spanish bumetanida (producto), bumetanida (sustancia), bumetanida, Bumetanida
French Bumétanide
German Bumetanid
Italian Bumetanide
Portuguese Bumetanida

Ontology: Furosemide (C0016860)

Definition (CHV) a drug used as a diuretic
Definition (CHV) a drug used as a diuretic
Definition (CHV) a drug used as a diuretic
Definition (NCI) A sulfamoylanthranilic acid derivative, also known as frusemide, and potent loop diuretic. Furosemide is widely used to treat hypertension and edema. This agent is highly bound to albumin and is largely excreted unchanged in the urine.
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 (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 (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)
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D005665
SnomedCT 387475002, 81609008
LNC LP32693-1, LP16155-1, MTHU016795
English Frusemid, Frusemide, Fursemide, Benzoic acid, 5-(aminosulfonyl)-4-chloro-2-((2-furanylmethyl)amino)-, Furosemide, furosemide, FRS, FUROSEMIDE, furosemide (medication), Furosemide [Chemical/Ingredient], frusemide, fursemide, Furosemide (product), Furosemide (substance)
Swedish Furosemid
Czech furosemid
Finnish Furosemidi
Russian FRUSEMID, FUROSEMID, FURSEMID, ФРУСЕМИД, ФУРОСЕМИД, ФУРСЕМИД
Italian Fursemide, Frusemide, Furosemide
Croatian FUROSEMID
Spanish frusemida, furosemida (producto), furosemida (sustancia), furosemida, Frusemida, Furosemida, Fursemida
Polish Furosemid, Lasix
Japanese フルセミド, フロセミド
French Furosémide
German Frusemid, Furosemid, Fursemid
Portuguese Frusemida, Furosemida, Fursemida

Ontology: torsemide (C0076840)

Definition (NCI) An anilinopyridine sulfonylurea belonging to the class of loop diuretics. Torsemide has a prolonged duration of action compared to other loop diuretics, is extensively protein bound in plasma and has a relatively long half-life.
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH C026116
SnomedCT 318034005, 108476002
English 1-isopropyl-3-((4-m-toluidino-3-pyridyl)sulfonyl)urea, torasemide, torsemide, 1-isopropyl-3-((4-(3-methylphenylamino)pyridine)-3-sulfonyl)urea, torsemide (medication), TORSEMIDE, torsemide [Chemical/Ingredient], Torasemide, Torsemide, Torasemide (product), Torsemide (substance), Torasemide (substance)
Spanish torasemida (sustancia), torsemida, torsemida (sustancia), torasemida (producto), torasemida

Ontology: Demadex (C0243946)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH C026116
English Demadex, demadex

Ontology: Lasix (C0699992)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D005665
English lasix, Lasix

Ontology: Bumex (C0701009)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D002034
English bumex, Bumetanide Roche Brand, Roche Brand of Bumetanide, Bumex