Pharm
Loop Diuretic
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Loop Diuretic
, Furosemide, Lasix, Bumetanide, Bumex, Torsemide, Demadex, Ethacrynic Acid, Edecrin
Indications
Symptomatically reduce pulmonary and
Peripheral Edema
Renal Insufficiency
Congestive Heart Failure
Emergency Management of Pulmonary Congestion (Lasix)
Left Ventricular Dysfunction
(CHF)
Contraindications
Sulfonamide Allergy
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
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
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
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
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
Adverse Effects
Risk of central volume depletion (dehydration)
Hypotension
Electrolyte
abnormalities
Metabolic Alkalosis
Hypokalemia
Hypomagnesemia
Hypocalcemia
Hyponatremia
Hyperosmolality
Renal dysfunction
Minimize dosage when starting an
ACE Inhibitor
Loop Diuretic Resistance Mechanisms
Renal Insufficiency
Renal Toxin
(e.g.
NSAID
) decreases GFR
NSAID
s
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
CHF patient is an avid
Sodium
retainer
Sodium
is common in most foods
Chicken Noodle soup = 1200 meq
Milk 122 meq
Big Mac 1010 meq
Canned Spinach 910 meq
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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