Drugs List

Therapeutic Indications

Uses

Oliguria due to renal failure

Contraindications

Cardiac glycoside toxicity
Children under 12 years
Addison's disease
Anuria
Breastfeeding
Dehydration
Electrolyte imbalance
Galactosaemia
Hepatic coma
Hypotension
Hypovolaemia
Long QT syndrome
Pre-coma associated with hepatic cirrhosis
Renal damage secondary to nephrotoxic agents
Renal impairment secondary to hepatotoxic agents
Severe hypokalaemia
Severe hyponatraemia
Torsade de pointes

Precautions and Warnings

Elderly
Family history of long QT syndrome
Hypoproteinaemia
Predisposition to hypotension
Adrenal disorder
Benign prostatic hyperplasia
Cardiac impairment
Diabetes mellitus
Glucose-galactose malabsorption syndrome
Gout
Hepatic impairment
Hepato-renal syndrome
History of gout
History of torsade de pointes
Lactose intolerance
Metabolic alkalosis
Pregnancy
Urinary obstruction

Correct electrolyte disorders before treatment
Correct hypotension before initiating treatment
May decrease glucose tolerance in patients with diabetes mellitus
Advise ability to drive/operate machinery may be affected by side effects
Correct hypovolaemia prior to administration
Contains lactose
Consider monitoring ECG in patients at risk of QT prolongation
Monitor blood / urinary glucose concentrations in diabetic patients
Monitor blood / urinary glucose in patients suspected of latent diabetes
Monitor creatinine, blood urea nitrogen (BUN) and urinary output
Monitor fluid and electrolyte status
Monitor for signs of blood dyscrasias eg fever, sore throat, malaise etc
Monitor hepatic function
Monitor patients at risk of gout
Monitor serum potassium regularly
Excess consumption of liquorice may increase the risk of hypokalaemia
May precipitate gout
Potassium supplements may be required
Discontinue treatment before glucose tolerance test
Discontinue if blood dyscrasia develops
Discontinue if evidence of significant bone marrow depression
Advise patient not to take NSAIDs unless advised by clinician

Only for use in patients with a marked reduction in glomerular filtration. Otherwise risk of increased excessive fluid and electrolyte losses.

Regular monitoring of serum potassium level is necessary in patients with impaired renal function and a creatinine clearance below 60 ml/minute/1.73 metre squared body surface area.

Patients who are at a high risk for radio contrast nephropathy, furosemide is not recommended to be used for diuresis as part of the preventative measures against radio contrast-induced nephropathy.

Serum cholesterol and triglyceride levels may increase during treatment but should return to normal within 6 months of discontinuation.

Pregnancy and Lactation

Pregnancy

Use furosemide with caution in pregnancy.

Furosemide has been given after the first trimester of pregnancy without causing foetal or newborn adverse effects. It should only be given during pregnancy if strictly indicated and for short-term treatment.

Schaefer (2007) states that diuretics are no longer part of the standard therapy for hypertension and oedema during pregnancy. They should only be used for particular indications. Furosemide can be given when treatment of heart or renal failure requires a diuretic.

A study between 1985 and 1992 showed that out of 350 neonates exposed to furosemide in the first trimester, 18 had major birth defects (such as cardiovascular defects and limb reduction defects) (Briggs, 2011).

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Furosemide is contraindicated in breastfeeding.

Furosemide should be discontinued during furosemide treatment as the drug may inhibit lactation and is secreted into the breast milk.

An alternative drug may be preferred especially whilst nursing a newborn or premature infant.

Hale (2010) states that it unlikely that the amount of furosemide transferred into breast milk would produce any effects in a nursing infant.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Acute renal failure
Aggravation of metabolic alkalosis
Agranulocytosis
Altered bowel habit
Anaphylactic reaction
Anaphylactoid reaction
Aplastic anaemia
Arrhythmias
Blood urea increased
Blurred vision
Bone marrow depression
Changes in hepatic function
Confusion
Constipation
Decrease in blood pressure
Decrease in high density lipoprotein (HDL)
Decrease in plasma calcium
Decreased glucose tolerance
Dehydration
Delayed reactions
Diarrhoea
Dizziness
Drowsiness
Dry mouth
Eosinophilia
Erythema multiforme
Exfoliative dermatitis
Fatigue
Fever
Gout
Haemolytic anaemia
Headache
Hearing loss (reversible)
Hepatic encephalopathy
Hyperglycaemia
Hyperuricaemia
Hypochloraemia
Hypokalaemia
Hypomagnesaemia
Hyponatraemia
Hypotension
Hypovolaemia
Impaired concentration
Increase in plasma triglyceride concentration
Increase in serum cholesterol (transient)
Increase in serum transaminases
Increased thirst
Interstitial nephritis
Intrahepatic cholestasis
Jaundice
Leucopenia
Light-headedness
Malaise
Metabolic alkalosis
Muscle cramps
Muscle weakness
Nausea
Nephrocalcinosis
Pancreatitis
Paraesthesia
Photosensitivity
Postural hypotension
Precipitation of diabetes
Pruritus
Psychiatric disorders
Purpura
Rash
Sensation of pressure
Serum creatinine increased
Severe bullous lesions
Shock
Tetany
Thrombocytopenia
Thrombosis
Tinnitus
Toxic epidermal necrolysis
Urinary incontinence
Urinary retention
Urticaria
Vasculitis
Visual disturbances
Vomiting
Weakness
Yellow vision

Presentation

High strength tablet formulation of furosemide

Drugs List

Therapeutic Indications

Uses

Oliguria due to renal failure

Dosage

Adults

Elderly

Children

Contraindications

Cardiac glycoside toxicity
Children under 12 years
Addison's disease
Anuria
Breastfeeding
Dehydration
Electrolyte imbalance
Galactosaemia
Hepatic coma
Hypotension
Hypovolaemia
Long QT syndrome
Pre-coma associated with hepatic cirrhosis
Renal damage secondary to nephrotoxic agents
Renal impairment secondary to hepatotoxic agents
Severe hypokalaemia
Severe hyponatraemia
Torsade de pointes

Precautions and Warnings

Elderly
Family history of long QT syndrome
Hypoproteinaemia
Predisposition to hypotension
Adrenal disorder
Benign prostatic hyperplasia
Cardiac impairment
Diabetes mellitus
Glucose-galactose malabsorption syndrome
Gout
Hepatic impairment
Hepato-renal syndrome
History of gout
History of torsade de pointes
Lactose intolerance
Metabolic alkalosis
Pregnancy
Urinary obstruction

Correct electrolyte disorders before treatment
Correct hypotension before initiating treatment
May decrease glucose tolerance in patients with diabetes mellitus
Advise ability to drive/operate machinery may be affected by side effects
Correct hypovolaemia prior to administration
Contains lactose
Consider monitoring ECG in patients at risk of QT prolongation
Monitor blood / urinary glucose concentrations in diabetic patients
Monitor blood / urinary glucose in patients suspected of latent diabetes
Monitor creatinine, blood urea nitrogen (BUN) and urinary output
Monitor fluid and electrolyte status
Monitor for signs of blood dyscrasias eg fever, sore throat, malaise etc
Monitor hepatic function
Monitor patients at risk of gout
Monitor serum potassium regularly
Excess consumption of liquorice may increase the risk of hypokalaemia
May precipitate gout
Potassium supplements may be required
Discontinue treatment before glucose tolerance test
Discontinue if blood dyscrasia develops
Discontinue if evidence of significant bone marrow depression
Advise patient not to take NSAIDs unless advised by clinician

Only for use in patients with a marked reduction in glomerular filtration. Otherwise risk of increased excessive fluid and electrolyte losses.

Regular monitoring of serum potassium level is necessary in patients with impaired renal function and a creatinine clearance below 60 ml/minute/1.73 metre squared body surface area.

Patients who are at a high risk for radio contrast nephropathy, furosemide is not recommended to be used for diuresis as part of the preventative measures against radio contrast-induced nephropathy.

Serum cholesterol and triglyceride levels may increase during treatment but should return to normal within 6 months of discontinuation.

Pregnancy and Lactation

Pregnancy

Use furosemide with caution in pregnancy.

Furosemide has been given after the first trimester of pregnancy without causing foetal or newborn adverse effects. It should only be given during pregnancy if strictly indicated and for short-term treatment.

Schaefer (2007) states that diuretics are no longer part of the standard therapy for hypertension and oedema during pregnancy. They should only be used for particular indications. Furosemide can be given when treatment of heart or renal failure requires a diuretic.

A study between 1985 and 1992 showed that out of 350 neonates exposed to furosemide in the first trimester, 18 had major birth defects (such as cardiovascular defects and limb reduction defects) (Briggs, 2011).

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Furosemide is contraindicated in breastfeeding.

Furosemide should be discontinued during furosemide treatment as the drug may inhibit lactation and is secreted into the breast milk.

An alternative drug may be preferred especially whilst nursing a newborn or premature infant.

Hale (2010) states that it unlikely that the amount of furosemide transferred into breast milk would produce any effects in a nursing infant.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Acute renal failure
Aggravation of metabolic alkalosis
Agranulocytosis
Altered bowel habit
Anaphylactic reaction
Anaphylactoid reaction
Aplastic anaemia
Arrhythmias
Blood urea increased
Blurred vision
Bone marrow depression
Changes in hepatic function
Confusion
Constipation
Decrease in blood pressure
Decrease in high density lipoprotein (HDL)
Decrease in plasma calcium
Decreased glucose tolerance
Dehydration
Delayed reactions
Diarrhoea
Dizziness
Drowsiness
Dry mouth
Eosinophilia
Erythema multiforme
Exfoliative dermatitis
Fatigue
Fever
Gout
Haemolytic anaemia
Headache
Hearing loss (reversible)
Hepatic encephalopathy
Hyperglycaemia
Hyperuricaemia
Hypochloraemia
Hypokalaemia
Hypomagnesaemia
Hyponatraemia
Hypotension
Hypovolaemia
Impaired concentration
Increase in plasma triglyceride concentration
Increase in serum cholesterol (transient)
Increase in serum transaminases
Increased thirst
Interstitial nephritis
Intrahepatic cholestasis
Jaundice
Leucopenia
Light-headedness
Malaise
Metabolic alkalosis
Muscle cramps
Muscle weakness
Nausea
Nephrocalcinosis
Pancreatitis
Paraesthesia
Photosensitivity
Postural hypotension
Precipitation of diabetes
Pruritus
Psychiatric disorders
Purpura
Rash
Sensation of pressure
Serum creatinine increased
Severe bullous lesions
Shock
Tetany
Thrombocytopenia
Thrombosis
Tinnitus
Toxic epidermal necrolysis
Urinary incontinence
Urinary retention
Urticaria
Vasculitis
Visual disturbances
Vomiting
Weakness
Yellow vision

Overdosage

It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.

The following number will direct the caller to the relevant local centre (0844) 892 0111

Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Further Information

Last Full Review Date: December 2014

Reference Sources

Drugs During Pregnancy and Lactation: Treatment Options and Risk Assessment, 2nd edition (2007) ed. Schaefer, C., Peters, P. and Miller, R. Elsevier, London.

Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 9th edition (2011) ed. Briggs, G., Freeman, R. and Yaffe, S. Lippincott Williams & Wilkins, Philadelphia.

Joint Formulary Committee. British National Formulary(online) London: BMJ Group and Pharmaceutical Press Accessed on 6 December 2014.

Martindale: The Complete Drug Reference, 37th edition (2011) ed. Sweetman, S. Pharmaceutical Press, London.

Medications and Mothers' Milk, 14th Edition (2010) Hale, T. Hale Publishing, Amarillo, Texas.

Paediatric Formulary Committee. BNF for Children (online) London: BMJ Group, Pharmaceutical Press, and RCPCH Publications Accessed on 6 December 2014.

Summary for Product Characteristics: Diuresal 500mg tablets. Ennogen Pharma Ltd. Revised May 2013.

Summary for Product Characteristics: Furosemide tablets BP 500mg. Actavis UK Ltd. Revised May 2013.

Summary for Product Characteristics: Furosemide 500mg tablets. Amdipharm Mercury Company Ltd. Revised January 2014.

US National Library of Medicine. Toxicology Data Network. Drugs and Lactation Database (LactMed).
Available at: https://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
Furosemide Last revised: 7 September, 2013
Last accessed: 6 January, 2014

The Drug Database for Acute Porphyria (NAPOS).
Available at: https://www.drugs-porphyria.org/monograph.php?id=1245
Furosemide Last revised: 22 September, 2009
Last accessed: 6 December, 2014

The Welsh Medicines Information Centre (WMIC).
Available at: www.wmic.wales.nhs.uk/porphyria_info.php
Furosemide Last revised: September, 2013
Last accessed: 6 December, 2014

European porphyria network.
Available at: www.porphyria-europe.org
Furosemide
Last accessed: 6 December, 2014