II. Indications
- Symptomatically reduce pulmonary and Peripheral Edema
- Emergency Management of Pulmonary Congestion (Lasix)
III. Contraindications
IV. Mechanism
- Potently inhibits reabsorption of Sodium and chloride
- Action at ascending loop of Henle in glomerulus
- Direct Venodilation in Pulmonary edema
- Reduces venous return (Preload)
- Reduces Central Venous Pressure
- Synergistic effect with Morphine and Nitroglycerin
- Reduces Intravascular Volume
- Reduces Cardiac Output
- Beware Hypotension in Myocardial Infarction
V. Preparations: Bumetanide (Bumex)
- Oral dosing (adults)
- Start: 0.5 to 1 mg orally twice daily
- Maximum: 10 mg/day
- Duration: 4-6 hours
- Intravenous dosing (adults)
- Start: 1 mg IV/dose (Max: 4-8 mg/dose)
- Intravenous Infusion (adults)
- Load: 1 mg IV
- Rate: 0.5 to 2 mg/hour IV
VI. Preparations: Furosemide (Lasix)
- Precautions
- Lasix (named for LAst SIX) is only effective for 6 hours
- Optimal dosing is given at least twice daily (patient otherwise is Sodium avid 18 hours/day)
- Oral Dosing (adults)
- Start: 20-40 mg orally daily to twice daily
- Maximum: 600 mg/day (rare to exceed 400 mg/day)
- Duration: 6-8 hours
- Intravenous Dosing
- Administer slowly over 1-2 minutes
- Bolus: 20-40 mg IV (0.5-1.0 mg/kg, max 2 mg/kg)
- Infusion: 0.25 to 0.75 mg/kg/hour
- Onset: Diuresis starts within 10 minutes
- Duration: 6 hours (Peak effect in 30 minutes)
- Intravenous Infusion
- Load: 40 mg
- Rate: 10-40 mg/hour IV
VII. Preparations: Torsemide (Demadex)
- Oral Dosing (adults)
- Start: 10-20 mg orally daily
- Maximum: 200 mg/day
- Duration: 12-16 hours
- Intravenous Dosing (adults)
- Start: 10 mg IV
- Maximum: 100-200 mg/day
- Intravenous Infusion (adults)
- Load: 20 mg
- Rate: 5-20 mg/hour
VIII. Preparations: Ethacrynic Acid (Edecrin)
- Oral Dosing
- Start: 25 mg orally daily
- Maximum: 200-400 mg divided 2-3 times daily
- Intravenous Dosing
- Start: 0.5 to 1 mg/kg IV up to 100 mg/dose
IX. Adverse Effects
- Risk of central volume depletion (dehydration)
- Hypotension
- Electrolyte abnormalities
- Renal dysfunction
- Minimize dosage when starting an ACE Inhibitor
X. Loop Diuretic Resistance Mechanisms
-
Renal Insufficiency
- Renal Toxin (e.g. NSAID) decreases GFR
- NSAIDs
- Decreased Diuretic oral absorption
- Structural changes in the Kidney
- Normal aging
- Distal tubular hypertrophy (long term use)
- Consider adding a Thiazide Diuretic
- Counters distal tubular reabsorption
- Significantly boosts Loop Diuretic effect
- Increased dietary Sodium intake
XI. Precautions
- All Loop Diuretics except Torsemide need to be dosed twice daily for effect
- Loop Diuretics are associated with significant electrolyte abnormalities and volume depletion (FDA black box warning)
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| Furosemide (on 6/18/2017 at Walmart.com) | ||
| Furosemide 20mg | #30 tablets for $4.00 | $0.13 each |
| Furosemide 20mg | #90 tablets for $10.00 | $0.11 each |
| Furosemide 40mg | #30 tablets for $4.00 | $0.13 each |
| Furosemide 40mg | #90 tablets for $10.00 | $0.11 each |
| Furosemide 80mg | #30 tablets for $4.00 | $0.13 each |
| Furosemide 80mg | #90 tablets for $10.00 | $0.11 each |
| furosemide (on 5/17/2017 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
| FUROSEMIDE 10 MG/ML SOLUTION | Generic | $0.10 per ml |
| FUROSEMIDE 20 MG TABLET | Generic | $0.02 each |
| FUROSEMIDE 40 MG TABLET | Generic | $0.02 each |
| FUROSEMIDE 80 MG TABLET | Generic | $0.04 each |
| lasix (on 3/8/2017 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
| LASIX 20 MG TABLET | Generic | $0.02 each |
| LASIX 40 MG TABLET | Generic | $0.02 each |
| bumetanide (on 5/17/2017 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
| BUMETANIDE 0.5 MG TABLET | Generic | $0.66 each |
| BUMETANIDE 1 MG TABLET | Generic | $0.61 each |
| BUMETANIDE 2 MG TABLET | Generic | $1.12 each |
| torsemide (on 5/17/2017 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
| TORSEMIDE 10 MG TABLET | Generic | $0.08 each |
| TORSEMIDE 100 MG TABLET | Generic | $0.28 each |
| TORSEMIDE 20 MG TABLET | Generic | $0.09 each |
| TORSEMIDE 5 MG TABLET | Generic | $0.06 each |
| edecrin (on 5/18/2016 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
| EDECRIN 25 MG TABLET | $21.72 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: Ethacrynic Acid (C0014963)
| Definition (NCI) | An unsaturated ketone derivative of aryloxyacetic acid without a sulfonamide substituent belonging to the class of loop diuretics. Ethacrynic acid is extensively bound to plasma proteins; both ethacrynic acid in its unchanged form as well as its metabolites are excreted in bile and urine. |
| Definition (MSH) | A compound that inhibits symport of sodium, potassium, and chloride primarily in the ascending limb of Henle, but also in the proximal and distal tubules. This pharmacological action results in excretion of these ions, increased urinary output, and reduction in extracellular fluid. This compound has been classified as a loop or high ceiling diuretic. |
| Definition (PDQ) | An aryloxy-acetic acid derivative belonging to the class of loop diuretics. Ethacrynic acid interferes with the chloride binding site of the Na+, K+, Cl- cotransporter system in the thick ascending loop of Henle, thereby inhibiting the reabsorption of sodium, potassium, and chloride ions. This leads to an increase in the excretion of sodium, potassium, chloride, calcium, and water. Check for "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=41163&idtype=1" active clinical trials or "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=41163&idtype=1&closed=1" closed clinical trials using this agent. ("http://nciterms.nci.nih.gov:80/NCIBrowser/ConceptReport.jsp?dictionary=NCI_Thesaurus&code=C485" NCI Thesaurus) |
| Concepts | Pharmacologic Substance (T121) , Organic Chemical (T109) |
| MSH | D004976 |
| SnomedCT | 373536004, 81947000 |
| English | Acid, Etacrynic, Acid, Ethacrynic, Etacrynic Acid, Acetic acid, (2,3-dichloro-4-(2-methylene-1-oxobutyl)phenoxy)-, Acid, Ethacrinic, Ethacrinic Acid, [2,3-Dichloro-4-(2-methylene-1-oxobutyl)phenoxy]acetic Acid, ethacrynic acid, EA, ethacrynic acid (medication), Ethacrynic Acid, Ethacrynic Acid [Chemical/Ingredient], ethacrinic acid, etacrynic acid, Ethacrynic acid, Ethacrynic acid product, Etacrynic acid, Ethacrynic acid (product), Ethacrynic acid (substance), Etacrynic acid product, ETHACRYNIC ACID |
| Swedish | Etakrynsyra |
| Czech | kyselina ethakrynová |
| Finnish | Etakryynihappo |
| Russian | ETAKRINOVAIA KISLOTA, ЭТАКРИНОВАЯ КИСЛОТА |
| Japanese | エタクリン酸 |
| Croatian | ETAKRINSKA KISELINA |
| Polish | Kwas etakrynowy |
| Spanish | ácido etacrínico (producto), ácido etacrínico (sustancia), ácido etacrínico, Ácido Etacrínico |
| French | Acide étacrynique |
| German | Etacrynsäure |
| Italian | Acido etacrinico |
| Portuguese | Ácido Etacrínico |
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: Loop Diuretics (C0354100)
| Definition (NCI) | Any agent belonging to the class of loop diuretics. Loop diuretics block and inhibit the function of the sodium-potassium-chloride (Na+, K+, Cl-) cotransporter system in the thick ascending limb of the loop of Henle, thereby inhibiting the reabsorption of sodium, potassium, and chloride ions. This leads to an increase in the excretion of sodium, potassium, chloride, calcium, magnesium, ammonium and water. |
| Concepts | Pharmacologic Substance (T121) |
| MSH | D049994 |
| SnomedCT | 371334009, 372691009, 29051009 |
| English | Loop Diuretic, LOOP DIURETICS, loop-acting diuretics (medication), loop-acting diuretics, [CV702] LOOP DIURETICS, diuretics loop, loop diuretics, loop diuretic, Loop Diuretics, Loop diuretic product (product), Loop diuretic, Loop diuretic (substance), Loop diuretic (product), Loop diuretic product, Diuretics, Loop |
| French | Diurétiques de l'anse, Diurétiques de l'anse de Henle |
| Czech | kličková diuretika |
| German | Schleifendiuretika |
| Spanish | producto con diurético de asa, producto con diurético de asa (producto), diurético de asa (sustancia), diurético de asa, diurético de asa (producto) |
Ontology: Edecrin (C0591434)
| Concepts | Pharmacologic Substance (T121) , Organic Chemical (T109) |
| MSH | D004976 |
| English | edecrin, Edecrin |
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 |
