COMPOSITION:
Each 1ml ampoule contains 10mg Furosemide.
Excipients:
Sodium Hydroxide, Sodium Chloride, Water for injection
Mechanism of action:
Pharmacotherapeutic Group: High-ceiling diuretic sulfonamides, loop diuretics;
The principle renal action of furosemide is to inhibit active chloride transport in the thick ascending limb. Re-absorption of sodium, chloride from the nephron is reduced and a hypotonic or isotonic urine produced.
Pharmacokinetic properties :
Absorption:Approximately 65% of the dose is absorbed after oral administration. The plasma half-life is biphasic with a terminal elimination phase of about 1½ hours.
Distribution: Furosemide is up to 99% bound to plasma proteins.
Elimination: Regardless of route of administration 69-97% of activity from a radio-labelled dose is excreted in the first 4 hours after the drug is given. Furosemide is mainly eliminated via the kidneys (80-90%) mainly excreted in the urine, largely unchanged; but also excreted in the bile, non-renal elimination being considerably increased in renal failure. Furosemide crosses the placental barrier and is excreted in the milk.
In renal/ hepatic impairment:
Where liver disease is present, biliary elimination is reduced up to 50%. Renal impairment has little effect on the elimination rate of furosemide, but less than 20% residual renal function increases the elimination time.
The elderly:
The elimination of furosemide is delayed in the elderly where a certain degree of renal impairment is present.
New born:
A sustained diuretic effect is seen in the newborn, possibly due to immature tubular function.
Indications:
Furosemide is a potent diuretic and is recommended for use when prompt and effective diuresis is required.
When a prompt diuresis is required. Use in emergencies or when oral therapy is precluded. Indications include:
- Oedema and/or ascites caused by cardiac or hepatic diseases
- Oedema caused by renal diseases (in case of nephrotic syndrome, treatment of the underlying disease is essential)
- Pulmonary oedema (e.g. in case of acute heart failure)
- Hypertensive crisis (in addition to other therapeutic measures)
Furosemide Injection 250mg/25ml is for use in the management of oliguria due to acute or chronic renal insufficiency with a glomerular filtration rate below 20ml/minute.
Contraindications:
•Hypersensitivity to the active substance or to any of the excipients.
•Hypersensitivity to amiloride, sulphonamides or sulphonamide derivatives
•Hypovolaemia and dehydration (with or without accompanying hypotension) .
•Severe hypokalaemia: severe hyponatraemia .
•Comatose or pre-comatose states associated with hepatic cirrhosis .
•Anuria or renal failure with anuria not responding to furosemide, renal failure as a result of poisoning by nephrotoxic or hepatotoxic agents, renal failure associated with hepatic coma
•Impaired renal function with a creatinine clearance below 30ml/min per 1.73 m body surface area .
•Addison's disease, Digitalis intoxication, Porphyria and Breast-feeding women.
Warnings/Precautions:
Conditions requiring correction before furosemide is started :
Hypotension,.Hypovolaemia. ,Severe electrolyte disturbances – particularly hypokalaemia, hyponatraemia and acid-base disturbances.
Furosemide is not recommended:
In patients at high risk for radiocontrast nephropathy - it should not be used for diuresis as part of the preventative measures against radiocontrast-induced nephropathy.
In patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption.
Particular caution and/or dose reduction required:
Symptomatic hypotension leading to dizziness, fainting or loss of consciousness can occur in patients treated with
furosemide, particularly in the elderly, patients on other medications which can cause hypotension and patients with other medical conditions that are risks for hypotension.
Elderly people (lower initial dose as particularly susceptible to side-effects )
difficulty with micturition including prostatic hypertrophy (increased risk of urinary retention: consider lower dose). Closely monitor patients with partial occlusion of the urinary tract
diabetes mellitus (latent diabetes may become overt: insulin requirements in established diabetes may increase: stop furosemide before a glucose tolerance test
Pregnancy, gout (furosemide may raise uric acid levels/precipitate gout),
patients with hepatorenal syndrome, impaired hepatic and renal function
( monitoring required), adrenal disease (contraindication in Addison's disease)
hypoproteinaemia e.g. nephritic syndrome (effect of furosemide may be impaired and its ototoxicity potentiated – cautious dose titration required).
acute hypercalcaemia (dehydration results from vomiting and diuresis - correct before giving furosemide). Treatment of hypercalcaemia with a high dose of furosemide results in fluid and electrolyte depletion - meticulous fluid replacement and correction of electrolyte required.
Patients who are at risk from a pronounced fall in blood pressure
premature infants (possible development nephrocalcinosis/nephrolithiasis; renal function must be monitored and renal ultrasonography performed).
Laboratory monitoring requirements:
Serum sodium:Particularly in the elderly people or in patients liable to electrolyte deficiency
Serum potassium :The possibility of hypokalaemia should be taken into account, in particular in patients with cirrhosis of the liver, those receiving concomitant treatment with corticosteroids, those with an unbalanced diet and those who abuse laxatives.
Regular monitoring of the potassium, and if necessary treatment with a potassium supplement, is recommended in all cases, but is essential at higher doses and in patients with impaired renal function. It is especially important in the event of concomitant treatment with digoxin, as potassium deficiency can trigger or exacerbate the symptoms of digitalis intoxication A potassium-rich diet is recommended during long-term use.
Frequent checks of the serum potassium are necessary in patients with impaired renal function and creatinine clearance.
below 60ml/min per 1.73m2 body surface area as well as in cases where furosemide is taken in combination with certain other drugs which may lead to an increase in potassium levels .
Renal function:
Frequent BUN in first few months of treatment, periodically thereafter. Long-term/high-dose BUN should regularly be measured. Marked diuresis can cause reversible impairment of kidney function in patients with renal dysfunction. Adequate fluid intake is necessary in such patients. Serum creatinine and urea levels tend to rise during treatment.
Glucose :Adverse effect on carbohydrate metabolism - exacerbation of existing carbohydrate intolerance or diabetes mellitus. Regular monitoring of blood glucose levels is desirable.
Other electrolytes:
Patients with hepatic failure/alcoholic cirrhosis are particularly at risk of hypomagnesia (as well as hypokalaemia). During long-term therapy (especially at high doses) magnesium, calcium, chloride, bicarbonate and uric acid should be regularly measured.
Other alterations in lab values:
Serum cholesterol and triglycerides may rise but usually return to normal within 6 months of starting furosemide.
Adverse Reactions:
Endocrine disorder: Glucose tolerance may decrease with furosemide. In patients with diabetes mellitus this may lead to a deterioration of metabolic control; latent diabetes mellitus may become manifest. Insulin requirements of diabetic patients may increase.
Eye disorders :Uncommon: visual disturbance
Ear and labyrinth disorders :Hearing disorders and tinnitus, although usually transitory, may occur in rare cases, particularly in patients with renal failure, hypoproteinaemia (e.g. in nephritic syndrome) and/or when intravenons furosemide has been given too rapidly.
Uncommon: Deafness (sometimes irreversible)
Cardiac disorders Uncommon: Cardiac arrhythmias
Furosemide may cause a reduction in blood pressure which, if pronounced may cause signs and symptoms such as impairment of concentration and reactions, light headedness, sensations of pressure in the head, headache, dizziness, drowsiness, weakness, disorders of vision, dry mouth, orthostatic intolerance. The diuretic effect of furosemide can result in hypovolaemia and dehydration, especially in the elderly. There is an increased risk of thrombosis.
Skin and subcutaneous tissue disorders Uncommon: Photosensitivity
Metabolism and nutrition disorder : As with other diuretics, electrolytes and water balance may be disturbed as a result of diuresis after prolonged therapy.Furosemide leads to increased excretion of sodium and chloride and consequently increase excretion of water. In addition,excretion of other electrolytes (in particular potassium, calcium and magnesium) is increased.
Metabolic acidosis can also occur. The risk of this abnormality increases at higher dosages and is influenced by the underlying disorder (e.g. cirrhosis of the liver, heart failure), concomitant medication and diet.
Symptomatic electrolyte disturbances and metabolic alkalosis may develop in the form of a gradually increasing electrolyte deficit or e.g. where higher furosemide doses are administered to patients with normal renal function, acute severe electrolyte losses
Symptoms of electrolyte imbalance depend on the type of disturbance:
Sodium deficiency can occur; this can manifest itself in the form of confusion, muscle cramps, muscle weakness, loss of appetite, dizziness, drowsiness and vomiting.
Potassium deficiency manifests itself in neuromuscular symptoms (muscular weakness, paralysis), intestinal symptoms (vomiting, constipation), renal symptoms (polyuria) or cardiac symptoms. Severe potassium depletion can result in paralytic ileus or confusion, which can result in coma.
Nephrocalcinosis/Nephrolithiasis has been reported in premature infants.
As with other diuretics, treatment with furosemide may lead to transitory increase in blood creatinine and urea levels.
Serum levels of uric acid may increase and attacks of gout may occur.
The diuretic action of furosemide may lead to or contribute to hypovolaemia and dehydration, especially in elderly patients.
Severe fluid depletion may lead to haemoconcentration with a tendency for thromboses to develop.
Increased production of urine may provoke or aggravate complaints in patients with an obstruction of urinary outflow. Thus,acute retention of urine with possible secondary complications may occur. For example, in patients with bladder-emptying disorders, prostatic hyperplasia or narrowing of the urethra.
Congenital, familial and genetic disorders: If furosemide is administered to premature infants during the first weeks of life, it may increase the risk of persistence of patent ductus arteriosus.
General disorders and administration site conditions Uncommon: Fatigue
Gastrointestinal disorders ;Uncommon: dry mouth, thirst, nausea, bowel motility disturbances, vomiting, diarrhea, constipation.
Renal and urinary disorders :Uncommon: interstitial nephritis, acute renal failure.Increased urine production, urinary incontinence, can be caused or symptoms can be exacerbated in patients with urinary
tract obstruction. Acute urine retention, possibly accompanied by complications, can occur for example in patients with bladder disorders, prostatic hyperplasia or narrowing of the urethra.
Drug Interactions:
General- The dosage of concurrently administered cardiac glycosides, diuretics, anti-hypertensive agents, or other drugs with blood-pressure-lowering potential may require adjustment as a more pronounced fall in blood pressure must be anticipated if given concomitantly with furosemide.
The toxic effects of nephrotoxic drugs may be increased by concomitant administration of potent diuretics such as furosemide.
Some electrolyte disturbances (e.g. hypokalaemia, hypomagnesaemia) may increase the toxicity of certain other drugs (e.g. digitalis preparations and drugs inducing QT interval prolongation syndrome).
Antihypertensives: enhanced hypotensive effect possible with all types. Concurrent use with ACE inhibitors or Angiotensin II receptor antagonists can result in marked falls in blood pressure, furosemide should be stopped or the dose reduced before starting an ACE-inhibitor or Angiotensin II receptor antagonists .
Antipsychotics: furosemide-induced hypokalaemia increases the risk of cardiac toxicity. Avoid concurrent use with pimozide. Increased risk of ventricular arrhythmias with amisulpride or sertindole. Enhanced hypotensive effect with phenothiazines.
When administering risperidone, caution should be exercised and the risks and benefits of the combination or co-treatment with furosemide or with other potent diuretics should be considered prior to the decision to use.
Anti-arrhythmics (including amiodarone, disopyramide, flecanaide and sotalol): risk of cardiac toxicity (because of furosemide-induced hypokalaemia). The effects of lidocaine, tocainide or mexiletine may be antagonised by furosemide.
Cardiac glycosides: hypokalaemia and electrolyte disturbances (including hypomagnesia) increase the risk of cardiac toxicity.
Drugs that prolong Q-T interval – increased risk of toxicity with furosemide-induced electrolyte disturbances.
Vasodilators: enhanced hypotensive effect with moxisylyte (thymoxamine) or hydralazine
Other diuretics: profound diures is possible when furosemide given with metolazone.
Increased risk of hypokalaemia with thiazides.
Renin inhibitors: aliskiren reduces plasma concentrations of furosemide.
Nitrates: enhanced hypotensive effect:
Lithium: In common with other diureticsserum lithium levels may be increased when lithium is given concomitantly with furosemide, resulting in increased lithium toxicity, including increased risk of cardiotoxic and neurotoxic effects of lithium. Therefore, it is recommended that lithium levels are carefully monitored and where necessary the lithium dosage is adjusted in patients receiving this combination.
Chelating agents: sucralfate may decrease the gastro-intestinal absorption of furosemide – the 2 drugs should be taken at least 2 hours apart.
NSAIDs: increased risk of nephrotoxicity. Indometacin and ketorolac may antagonise the effects of furosemide (avoid if possible). NSAIDs may attenuate the action of furosemide and may cause acute renal failure in cases of pre-existing hypovolaemia or dehydration.
Salicylates: effects may be potentiated by furosemide. Salycylic toxicity may be increased by furosemide
Antibiotics: increased risk of ototoxicity with aminoglycosides, polymixins or vancomycin - only use concurrently if compelling reasons. Increased risk of nephrotoxicity with aminoglycosides or cefaloridine. Furosemide can decrease vancomycin serum levels after cardiac surgery. Increased risk of hyponatraemia with trimethoprim. Impairment of renal function may develop in patients receiving concurrent treatment with furosemide and high doses of certain cephalosporins.
Antidepressants: enhanced hypotensive effect with MAOIs. Increased risk of postural hypotension with TCAs (tricyclic antidepressants). Increased risk of hypokalaemia with reboxetine
Antidiabetics: hypoglycaemic effects antagonised by furosemide
Antiepileptics: increased risk of hyponatraemia with carbamazepine. Diuretic effect reduced by phenytoin.
Antihistamines: hypokalaemia with increased risk of cardiac toxicity
Antifungals: increased risk of hypokalaemia and nephrotoxicity with amphotericin
Anxiolytics and hypnotics: enhanced hypotensive effect. Chloral or triclorfos may displace thyroid hormone from binding site.
CNS stimulants (drugs used for ADHD): hypokalaemia increases the risk of ventricular arrhythmias
Corticosteroids: diuretic effect anatgonised (sodium retention) and increased risk of hypokalaemia
Glychyrrizin: (contained in liquorice) may and increase the risk of developing hypokalaemia.
Cytotoxics – increased risk of nephrotoxicity and ototoxicity with platinum compounds/cisplatin. Nephrotoxicity of cisplatin may be enhanced if furosemide is not given in low doses (e.g. 40 mg in patients with normal renal function) and with positive fluid balance when used to achieve forced diuresis during cisplatin treatment.
Dopaminergics: enhanced hypotensive effect with levodopa.
Immunomodulators: enhanced hypotensive effect with aldesleukin. Increased risk of hyperkalaemia with ciclosprin and tacrolimus. Increased risk of gouty arthritis with ciclosporin
Muscle relaxants: enhanced hypotensive effect with baclofen or tizanidine. Increased effect of curare-like muscle
Relaxants.
Oestrogens: diuretic effect antagonised
Progestogens (drosperidone): increased risk of hyperkalaemia
Prostaglandins: enhanced hypotensive effect with alprostadil
Sympathomimetics: increased risk of hypokalaemia with high doses of beta sympathomimetics
Theophylline: enhanced hypotensive effect
Probenecid: effects of furosemide may be reduced by probenecid and furosemide may reduce renal clearance of
probenecid.
Anaesthetic agents: general anaesthetic agents may enhance the hypotensive effects of furosemide. The effects of curare may be enhanced by furosemide.
Alcohol: enhanced hypotensive effect.
Laxative abuse: increases the risk of potassium loss
Others: Concomitant administration of aminoglutethimide may increase the risk of hyponatraemia.
Pregnancy and Lactation:
Furosemide crosses the placental barrier and should not be given during pregnancy unless there are compelling medical reasons. It should only be used for the pathological causes of oedema which are not directly or indirectly linked to the pregnancy. The treatment with diuretics of oedema and hypertension caused by pregnancy is undesirable because placental perfusion can be reduced, so, if used, monitoring of fetal growth is required. However, furosemide has been given after the first trimester of pregnancy for oedema, hypertension and toxaemia of pregnancy without causing fetal or newborn adverse effects.
Furosemide is contraindicated during lactation as it passes into breast milk and may inhibit lactation.
Effects on ability to drive and use machines:
Reduced mental alertness, dizziness and blurred vision have been reported, particularly at the start of treatment, with dose changes and in combination with alcohol. Patients should be advised that if affected, they should not drive, operate machinery or take part in activities where these effects could put themselves or others at risk.
DOSAGE AND ADMINISTRATION:
Furosemide Injection 20mg/2ml , 40mg/4ml and 50mg/5ml are for intramuscular or for intravenous administration and must always be given slowly. Furosemide Injection 250mg/25ml is for slow intravenous administration.
Furosemide Injection 20mg/2ml , 40mg/4ml and 50mg/5ml
Adults: Initially, doses of 20 - 50mg may be administered by the intramuscular route, or by slow intravenous injection at a rate not exceeding 4mg/minute. The diuretic effect of furosemide is proportional to the dosage and, if larger doses are required, they should be given as a controlled infusion at a rate not exceeding 4mg/minute and titrated according to the response.
Elderly: Elimination of furosemide is generally slower in the elderly. Dosage should be titrated until the required effect is achieved.
Paediatric population: Dosages for children range from 0.5 - 1.5mg/kg weight daily up to a maximum total daily dose of 20mg.
Furosemide Injection 250mg/25ml
Adults: Furosemide Injection 250mg/25ml is for slow intravenous injection at a rate not exceeding 4mg/minute.
An initial dose of 250mg (one 25ml ampoule) 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 ampoules) 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 1,000mg (four 25ml ampoules) in an appropriate infusion fluid may be given. The rate of infusion should never exceed 4mg/minute.
If the third infusion (1,000mg 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 aforementioned 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. The rate of infusion should still never exceed 4mg/min.
If the response to either method of administration is satisfactory (urine output 40 - 50ml/hour), the effective dose (of up to 1,000mg) 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.
Elderly: Elimination of furosemide is generally slower in the elderly. Dosage should be titrated until the required effect is achieved.
Paediatric population: Dosages for children must be determined on the basis of the severity of the renal insufficiency and on the clinical response to initial doses.
Overdose:
Features:
Overdose can cause massive diuresis resulting in dehydration, volume depletion and electrolyte disturbances with consequent hypotension and cardiac toxicity. High doses have the potential to cause transient deafness and may precipitate gout (disturbed uric acid secretion).
Management:
Benefits of gastric decontamination are uncertain. In patients presenting within 1 hour of ingestion, consider activated charcoal (50g for adults: 1g/kg for children).
Observe for a minimum of 4 hours - monitor pulse and blood pressure.
Treat hypotension and dehydration with appropriate IV fluids.
Monitor urinary output and serum electrolytes (including chloride and bicarbonate). Correct electrolyte imbalances. Monitor 12 lead ECG in patients with significant electrolyte disturbances.