Furosemide parenteral
- Drugs List
- Therapeutic Indications
- Dosage
- Administration
- Contraindications
- Precautions and Warnings
- Pregnancy and Lactation
- Side Effects
- Monograph
Presentation
Parenteral formulations of furosemide.
Drugs List
Therapeutic Indications
Uses
Forced diuresis
Hypercalcaemia
Oedema
Oliguria due to renal failure
Resistant hypertension
Dosage
Adults
Acute pulmonary oedema
40mg, given by slow intravenous injection, followed by further doses depending on the patients response.
A further dose of 20mg to 40mg may be given by slow intravenous injection if no satisfactory response is seen after 30 minutes to 60 minutes.
Oedema
A single dose of 20mg to 50mg may be given initially, intravenously or intramuscularly.
If the diuretic response is inadequate, the dose may be increased in 20mg increments every 2 hours until desired effect is obtained.
If doses greater than 50mg are required it is recommended that they be given by slow intravenous infusion.
Hypercalcaemia
Daily doses of 20mg to 240mg may be required to reach the desired diuresis rate of approximately 6 litres per day.
Forced diuresis
Repeated doses of 20mg to 80mg furosemide should be administered together with intravenous isotonic fluid at the rate of 500ml/hour. Diuresis aim is 11 to 12 litres per day.
The recommended maximum dose is 1.5 g daily.
Oliguria due to renal failure (250mg/ml injection)
An initial dose of 250mg (one 25ml vial) may be added to about 225ml sodium chloride injection B.P. or Ringer's solution for injection, and infused over one hour at a drip rate of 80 drops/minute (4mg/minute).
If urine output within the next hour is insufficient, a dose of 500mg (two 25ml vials) in an appropriate infusion fluid, the total volume of which must be governed by the patient's state of hydration, may be infused at a rate not exceeding 4mg/minute. If a satisfactory urine output has still not been achieved within one hour following the end of the second infusion, a third dose consisting of 1g (four 25ml vials) in an appropriate infusion fluid may be given.
If the third infusion (1g over 4 hours) is not effective, dialysis will probably be required.
In oliguric or anuric patients with significant fluid overload, it may not be practicable to use the previous method of administration. In such cases, the use of a constant-rate infusion pump with a micrometer screw-gauge adjustment may be considered for direct administration of the injection into the vein.
If the response to either method of administration is satisfactory (urine output 40 to 50ml/hour), the effective dose (of up to 1g) may be repeated every 24 hours. Alternatively, treatment may be maintained by oral administration of furosemide tablets, using 500mg by mouth for each 250mg required by injection. Appropriate adjustments to dosage may then be made according to the patient's response.
Resistant hypertension
20mg to 50mg by intramuscular injection, by slow intravenous injection, or by intravenous infusion.
If required, increase in steps of 20mg every 2 hours (by intramuscular injection or by intravenous injection, or by intravenous infusion). Give doses greater than 50 mg given by intravenous infusion only.
Maximum daily dose: 1.5g.
Palliative care of heart failure
The unlicensed administration of furosemide by subcutaneous injection or subcutaneous infusion has been used in the palliative care of advanced heart failure. Doses vary based on the patient's previous oral dose.
Elderly
Dose should be titrated until the required response is achieved as furosemide is generally eliminated more slowly in elderly patients.
Children
Doses range from 0.5mg/kg to 1.5mg/kg daily.
If the response is inadequate, increments of 1mg/kg at 2 hourly intervals may be used.
Single doses greater than 6mg/kg are not recommended.
Maximum daily dose is 20mg.
Maintenance therapy should be reduced to the minimum effective level.
The following specific dose regimes may be suitable:
Pulmonary oedema; Oedema in heart failure, renal disease, and hepatic disease
By slow intravenous injection
Children aged 12 to 18 years: 20mg to 40mg every 8 hours as required. In resistant cases, higher doses may be required.
Children aged 1 month to 11 years: 0.5mg/kg to 1mg/kg every 8 hours as required (up to a maximum of 40mg per dose every 8 hours, or 6mg/kg daily).
By continuous intravenous infusion
0.1 to 2mg/kg/hour.
Pulmonary oedema following cardiac surgery; Oedema in heart failure, renal disease, and hepatic disease following cardiac surgery
By continuous intravenous infusion
Initial dose: 100micrograms/kg/hour.
Maintenance dose: Double dose every 2 hours until urine output exceeds 1ml/kg/hour.
Oliguria
By intravenous infusion
Children aged 12 to 18 years
Initially, 250mg over 1 hour, then (if urine output not satisfactory) increase to 500mg over 2 hours. Then (if urine output not satisfactory) increase to 1g over 4 hours. If no response obtained dialysis probably required.
Doses of up to 1g can be given at a maximum rate of 4mg/minute repeated every 24 hours.
Children aged 1 month to 12 years
2mg/kg to 5mg/kg given up to four times a day.
Maximum daily dose: 1g.
Intravenous injections, give over 5 to 10 minutes at a usual rate of 100micrograms/kg/minute (not exceeding 500micrograms/kg/minute), maximum 4mg/minute.
Intravenous infusions, dilute with sodium chloride 0.9% to a concentration of 1 to 2mg/ml; glucose solutions unsuitable (infusion pH must be above 5.5).
Neonates
Pulmonary oedema; Oedema in heart failure, renal disease, and hepatic disease
By slow intravenous injection
0.5mg/kg to 1mg/kg every 12 to 24 hours.
OR
0.5mg/kg to 1mg/kg every 24 hours, if corrected gestational age under 31 weeks.
Intravenous injections, give over 5 to 10 minutes at a usual rate of 100micrograms/kg/minute (not exceeding 500micrograms/kg/minute), maximum 4mg/minute.
Intravenous infusions, dilute with sodium chloride 0.9% to a concentration of 1 to 2mg/ml; glucose solutions unsuitable (infusion pH must be above 5.5).
Patients with Renal Impairment
Careful monitoring is necessary in patients with hepatorenal syndrome.
Other renally impaired patients may be given an initial dose of 250mg diluted in 225ml of sodium chloride injection or Ringer's solution for injection administered over 1 hour (approximately 4mg/minute or 80 drops/minute). In patients with severe impairment (serum creatinine above 5mg/dl),it is recommended that a rate of 2.5mg/minute should not be exceeded.
If significant increase in urine output (4 to 50ml/hour) is not seen within the next hour, a second infusion of 500mg diluted in a sodium chloride injection or Ringer's solution for injection (volume determined by hydration state of patient) should be given over 2 hours.
A third infusion of 1g may be given over 4 hours if a satisfactory response is not achieved within 1 hour of the end of the second infusion.
If this third infusion fails dialysis will probably be required.
For oliguric or anuric patients with significant fluid overload the above method may not be suitable. These patients may benefit from use of a constant rate infusion pump with micrometer screw-gauge adjustment for the direct administration of the injection into the vein.
Once a satisfactory response (urine output of 40 to 50ml/hour) has been reached, the effective dose (up to 1g) may be repeated every 24 hour. Maintenance therapy may be continued using oral furosemide (dosage adjusted according to clinical response).
Patients with Hepatic Impairment
Patients with hepatic cirrhosis and ascites should be treated initially in hospital. Hypokalaemia may precipitate coma and there is an increased risk of hypomagnesaemia in patients with alcoholic cirrhosis.
Careful monitoring is necessary in patients with hepatorenal syndrome.
Additional Dosage Information
Treatment should be switched from parenteral administration to oral therapy as soon as appropriate.
Administration
For intravenous or intramuscular routes.
Unlicensed routes of subcutaneous injection and subcutaneous infusion.
In an emergency where oral therapy is inappropriate slow intravenous injection is preferred, intramuscular injection may be given in exceptional cases but is not suitable for acute conditions e.g. pulmonary oedema.
Furosemide must be injected or infused slowly. Maximum rate of 4mg per minute must not be exceeded.
In cases of severe renal impairment (serum creatinine greater than 5mg/dl), a maximum infusion rate of 2.5mg per minute must not be exceeded. Single doses of up to 80mg may be administered more rapidly.
A continuous furosemide infusion is preferred over repeated bolus injections. Where this is not possible a regimen of low dose bolus injections given at short intervals (approximately 4 hours) is preferred to a regimen of larger bolus doses at longer intervals.
Contraindications
Addison's disease
Anuria
Breastfeeding
Dehydration
Hepatic coma
Hypovolaemia
Long QT syndrome
Pre-coma associated with hepatic cirrhosis
Renal damage secondary to nephrotoxic agents
Renal impairment associated with hepatic coma
Renal impairment secondary to hepatotoxic agents
Severe hypokalaemia
Severe hyponatraemia
Torsade de pointes
Precautions and Warnings
Elderly
Family history of long QT syndrome
Hypoproteinaemia
Neonates
Predisposition to hypotension
Premature infants
Restricted sodium intake
Benign prostatic hyperplasia
Diabetes mellitus
Electrolyte imbalance
Gout
Hepatic cirrhosis
Hepatic impairment
Hepato-renal syndrome
History of torsade de pointes
Hyperuricaemia
Hypotension
Metabolic alkalosis
Pregnancy
Renal impairment
Systemic lupus erythematosus
Urinary obstruction
Advise patient to protect skin if restarting following photosensitivity
Correct electrolyte disorders before treatment
Correct hypotension before initiating treatment
Sodium content of formulation may be significant
Advise ability to drive/operate machinery may be affected by side effects
Correct hypovolaemia prior to administration
Not all available brands are licensed for all indications
Avoid concurrent use of products containing sorbitol
Avoid rapid infusion rates
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 blood urea
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 calcium levels
Monitor serum creatinine
Monitor uric acid levels
Premature infants: perform renal ultrasonography and monitor renal function
Progressive renal disease: discontinue if azotaemia and oliguria occurs
Excess consumption of liquorice may increase the risk of hypokalaemia
Increases in cholesterol and triglyceride levels may be seen
May precipitate gout
Discontinue if allergic reaction occurs
Discontinue if evidence of significant bone marrow depression
Discontinue if photosensitivity occurs
Advise patient not to take NSAIDs unless advised by clinician
Hypotensive effect enhanced by alcohol
Advise patient that transient hearing loss may occur
Monitor fluid, creatinine and electrolyte status. Profound diuresis may occur resulting in fluid and electrolyte depletion (sodium, potassium, chloride and bicarbonate). These deficiencies must be corrected or the treatment withdrawn. Correction of hypokalaemia by addition of potassium sparing agent may be necessary. During long-term or high dose therapy potassium supplements may be necessary.
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.
Animal studies in rats and rabbits have reported teratogenicity. No malformations in humans have been reported to date, however experience is limited. Furosemide reaches 100% of the maternal serum concentration in cord blood and also crosses the placenta. Increased foetal urine production has been reported following the use of furosemide. Use of diuretics may induce physiological hypovolaemia which decreases placental perfusion. Briggs (2015) states furosemide does not significantly alter amniotic fluid volume.
Furosemide is not recommended as standard therapy for hypertension and oedema during pregnancy. If use of a diuretic is essential to treat cardiac or renal insufficiency, furosemide may be used with caution. Careful monitoring of electrolytes, haematocrit and foetal growth is required. Use may predispose the foetus to hypercalciuria, nephrocalcinosis and secondary hyperparathyroidism.
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 is excreted in breast milk. It is frequently used in paediatric units (Hale, 2014) and because of the extremely poor bioavailability exhibited by furosemide in newborns very high doses are required. The amounts transferred into human milk would be very unlikely to produce any effects in infants, although theoretical suppression of lactation could occur. An alternative drug may be preferred especially whilst nursing a newborn or premature infant. Schaefer (2007) states that if furosemide is indicated then it may be prescribed.
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
Abdominal pain
Acute generalised exanthematous pustulosis
Acute pancreatitis
Aggravation of metabolic alkalosis
Agranulocytosis
Allergic reaction
Anaemia
Anaphylactic reaction
Anaphylactoid reaction
Aplastic anaemia
Arrhythmias
Bladder spasm
Blood urea increased
Bone marrow depression
Bullous pemphigoid
Burning sensation
Circulatory collapse
Confusion
Decrease in plasma calcium
Decreased glucose tolerance
Dehydration
Delayed reactions
Diarrhoea
Dizziness
Drowsiness
Drug rash with eosinophilia and systemic symptoms (DRESS)
Dry mouth
Eosinophilia
Erythema multiforme
Exfoliative dermatitis
Fatigue
Fever
Fluid and electrolyte disturbances
Gastro-intestinal symptoms
Gout
Haemolytic anaemia
Headache
Hearing loss
Hepatic encephalopathy
Hyperglycaemia
Hypersensitivity reactions
Hyperuricaemia
Hypokalaemia
Hypomagnesaemia
Hyponatraemia
Hypotension
Hypovolaemia
Impaired concentration
Impaired vision
Increase in plasma triglyceride concentration
Increase in serum cholesterol (transient)
Increase in serum transaminases
Increased sweating
Increased thirst
Injection site reactions
Interstitial nephritis
Intrahepatic cholestasis
Jaundice
Leucopenia
Light-headedness
Malaise
Metabolic alkalosis
Muscle cramps
Nausea
Nephrocalcinosis
Nephrolithiasis
Oliguria
Orthostatic dysregulation
Orthostatic hypotension
Pain on intramuscular injection
Paraesthesia
Photosensitivity
Precipitation of diabetes
Pruritus
Purpura
Rash
Renal failure
Sensation of pressure
Serum creatinine increased
Severe bullous lesions
Shock
Stevens-Johnson syndrome
Swelling
Syncope
Taste disturbances
Tetany
Thiamine deficiency
Thrombocytopenia
Thromboembolic disorders
Thrombophlebitis
Tinnitus
Toxic epidermal necrolysis
Urinary frequency
Urinary retention
Urticaria
Vasculitis
Vomiting
Weakness
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: November 2015
Reference Sources
Drugs During Pregnancy and Lactation: Treatment Options and Risk Assessment, 3rd edition (2015) ed. Schaefer, C., Peters, P. and Miller, R. Elsevier, London.
Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 10th edition (2015) ed. Briggs, G., Freeman, R. Wolters Kluwer Health, Philadelphia.
Martindale: The Complete Drug Reference (online) London: Brayfield A (ed). Pharmaceutical Press Accessed on 17 November 2015.
Medications and Mothers' Milk, Sixteenth Edition (2014) Hale, T and Rowe, H, Hale Publishing, Plano, Texas.
Palliative Care Formulary, Sixth Edition (2018) ed. Twycross, R., Wilcock, A. and Howard, P. Palliativedrugs.com Ltd, Nottingham.
Summary of Product Characteristics: Furosemide Injection BP (Hameln). Hameln Pharmaceuticals Ltd. Revised June 2015.
Summary of Product Characteristics: Furosemide 10mg/ml solution for injection or infusion, 20mg in 2ml and 250mg in 25ml. Wockhardt UK Ltd. Revised August 2015.
Summary of Product Characteristics: Furosemide 10mg/ml solution for injection or infusion. Accord Healthcare Ltd. Revised September 2016.
Summary of Product Characteristics: Furosemide 10mg/ml solution for injection/infusion. AS KALCEKS. Revised August 2020.
Summary of Product Characteristics: Furosemide Injection BP Minijet 10mg/ml Solution for Injection. International Medication Systems (UK) Ltd. Revised January 2013.
Summary of Product Characteristics: Lasix Injection 20mg/2ml. Sanofi. Revised January 2012.
NICE Evidence Services Available at: www.nice.org.uk Last accessed: 24 August 2017
The Norwegian Porphyria Centre (NAPOS).
Available at: https://www.drugs-porphyria.org
Last revised: 11 January 2012
Last accessed: 23 March 2018
The Welsh Medicines Information Centre (WMIC) - Porphyria Information Service.
Available at: https://www.wmic.wales.nhs.uk/porphyria_info.php
Last revised: May 2017
Last accessed: 23 March 2018
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: 09 January 2018
Last accessed: 23 March 2018
Medscape UK | Univadis prescription drug monographs & interactions are based on FDB Multilex Content
FDB Disclaimer : FDB Multilex is intended for the use of healthcare professionals and is provided on the basis that the healthcare professionals will retain FULL and SOLE responsibility for deciding what treatment to prescribe or dispense for any particular patient or circumstance.