Furosemide

Last updated

Furosemide
Furosemide.svg
Furosemide-1Z9Y-3D-balls.png
Clinical data
Pronunciation /fjʊˈroʊsəˌmaɪd/
Trade names Lasix, Furoscix, others
Other namesFurosemide
AHFS/Drugs.com Monograph
MedlinePlus a682858
License data
Pregnancy
category
  • AU:C
Routes of
administration 		oral, intravenous, intramuscular, subcutaneous
ATC code
Legal status
Legal status
  • AU: S4 (Prescription only)
  • UK: POM (Prescription only)
  • US: WARNING [1] Rx-only [2] [3]
  • In general: ℞ (Prescription only)
Pharmacokinetic data
Bioavailability 43–69%
Protein binding 91–99%
Metabolism Liver and kidney glucuronidation
Onset of action 30 to 60 min (PO), 5 min (IV) [4]
Elimination half-life up to 100 minutes
Excretion Kidney (66%), bile duct (33%)
Identifiers
  • 4-Chloro-2-[(furan-2-ylmethyl)amino]-5-sulfamoylbenzoic acid
CAS Number
PubChem CID
DrugBank
ChemSpider
UNII
KEGG
ChEBI
ChEMBL
CompTox Dashboard (EPA)
ECHA InfoCard 100.000.185 OOjs UI icon edit-ltr-progressive.svg
Chemical and physical data
Formula C12H11ClN2O5S
Molar mass 330.74 g·mol−1
3D model (JSmol)
  • o1cccc1CNc(cc2Cl)c(C(=O)O)cc2S(=O)(=O)N
  • InChI=1S/C12H11ClN2O5S/c13-9-5-10(15-6-7-2-1-3-20-7)8(12(16)17)4-11(9)21(14,18)19/h1-5,15H,6H2,(H,16,17)(H2,14,18,19) Yes check.svgY
  • Key:ZZUFCTLCJUWOSV-UHFFFAOYSA-N Yes check.svgY
   (verify)

Furosemide, sold under the brand name Lasix among others, is a loop diuretic medication used to treat edema due to heart failure, liver scarring, or kidney disease. [4] Furosemide may also be used for the treatment of high blood pressure. [4] It can be taken intravenously or orally. [4] When given intravenously, furosemide typically takes effect within five minutes; when taken orally, it typically metabolizes within an hour. [4]

Contents

Common side effects include orthostatic hypotension (decrease in blood pressure while standing, and associated lightheadedness), tinnitus (ringing in the ears), and photosensitivity (sensitivity to light). [4] Potentially serious side effects include electrolyte abnormalities, low blood pressure, and hearing loss. [4] It is recommended that serum electrolytes (especially potassium), serum CO2, creatinine, BUN levels, and liver and kidney functioning be monitored in patients taking furosemide. It is also recommended to be alert for the occurrence of any potential blood dyscrasias. [4] Furosemide is a type of loop diuretic that works by decreasing the reabsorption of sodium by the kidneys. [4] Common side effects of furosemide injection include hypokalemia (low potassium level), hypotension (low blood pressure), and dizziness. [5]

Furosemide was patented in 1959 and approved for medical use in 1964. [6] It is on the World Health Organization's List of Essential Medicines. [7] In the United States, it is available as a generic medication. [4] In 2022, it was the 24th most commonly prescribed medication in the United States, with more than 23 million prescriptions. [8] [9] In 2020/21 it was the twentieth most prescribed medication in England. [10] It is on the World Anti-Doping Agency's banned drug list due to concerns that it may mask other drugs. [11] It has also been used in race horses for the treatment and prevention of exercise-induced pulmonary hemorrhage. [12] [13]

Medical uses

Furosemide (Lasix) for injection. Lasix-box2016.jpg
Furosemide (Lasix) for injection.

Furosemide is primarily used for the treatment of edema, but also in some cases of hypertension (where there is also kidney or heart impairment). [14] It is often viewed as a first-line agent in most people with edema caused by congestive heart failure because of its anti-vasoconstrictor and diuretic effects. [4] [15] Compared with furosemide, however, torasemide (aka "torsemide") has been demonstrated to show improvements to heart failure symptoms, possibly lowering the rates of rehospitalization associated with heart failure, with no difference in risk of death. [16] [17] [18] Torsemide may also be safer than furosemide. [19] [20] Providing self-administered subcutaneous furosemide has been found to reduce hospital admissions in people with heart failure, resulting in significant savings in healthcare costs. [21] [22]

Furosemide is also used for liver cirrhosis, kidney impairment, nephrotic syndrome, in adjunct therapy for swelling of the brain or lungs where rapid diuresis is required (IV injection), and in the management of severe hypercalcemia in combination with adequate rehydration. [23]

Kidney disease

In chronic kidney diseases with hypoalbuminemia, furosemide is used along with albumin to increase diuresis. [24] It is also used along with albumin in nephrotic syndrome to reduce edema. [25]

Other information

Furosemide is mainly excreted by tubular secretion in the kidney. In kidney impairment, clearance is reduced, increasing the risk of adverse effects. [4] Lower initial doses are recommended in older patients (to minimize side effects) and high doses may be needed in kidney failure. [26] It can also cause kidney damage; this is mainly by loss of excessive fluid (i.e., dehydration), and is usually reversible.[ citation needed ]

Furosemide acts within 1 hour of oral administration (after IV injection, the peak effect is within 30 minutes). Diuresis is usually complete within 6–8 hours of oral administration, but there is significant variation between individuals. [27]

Adverse effects

Furosemide also can lead to gout caused by hyperuricemia. Hyperglycemia is also a common side effect. [28] [29] [30]

The tendency, as for all loop diuretics, to cause low serum potassium concentration (hypokalemia) has given rise to combination products, either with potassium or with the potassium-sparing diuretic amiloride (Co-amilofruse). Other electrolyte abnormalities that can result from furosemide use include hyponatremia, hypochloremia, hypomagnesemia, and hypocalcemia. [31]

In the treatment of heart failure, many studies have shown that the long-term use of furosemide can cause varying degrees of thiamine deficiency, so thiamine supplementation is also suggested. [32]

Furosemide is a known ototoxic agent generally causing transient hearing loss but can be permanent. Reported cases of furosemide-induced hearing loss appeared to be associated with rapid intravenous administration, high dosages, concomitant renal disease, and coadministration with other ototoxic medication. [33] [34] However, a recently reported longitudinal study showed that participants treated with loop diuretics over 10 years were 40% more likely to develop hearing loss and 33% more likely of progressive hearing loss compared to participants who did not use loop diuretics. [35] This suggests the long-term consequences of loop diuretics on hearing could be a more significant than previously thought and further research is required in this area.  

Other precautions include nephrotoxicity, sulfonamide (sulfa) allergy, and increased free thyroid hormone effects with large doses. [36]

Interactions

Furosemide has potential interactions with these medications: [37]

Potentially hazardous interactions with other drugs:

Mechanism of action

Furosemide, like other loop diuretics, acts by inhibiting the luminal Na–K–Cl cotransporter in the thick ascending limb of the loop of Henle, by binding to the Na-K-2Cl transporter, thus causing more sodium, chloride, and potassium to be excreted in the urine. [38]

The action on the distal tubules is independent of any inhibitory effect on carbonic anhydrase or aldosterone; it also abolishes the corticomedullary osmotic gradient and blocks negative, as well as positive, free water clearance. Because of the large NaCl absorptive capacity of the loop of Henle, diuresis is not limited by the development of acidosis, as it is with the carbonic anhydrase inhibitors.[ citation needed ]

Additionally, furosemide is a noncompetitive subtype-specific blocker of GABA-A receptors. [39] [40] [41] Furosemide has been reported to reversibly antagonize GABA-evoked currents of α6β2γ2 receptors at μM concentrations, but not α1β2γ2 receptors. [39] [41] During development, the α6β2γ2 receptor increases in expression in cerebellar granule neurons, corresponding to increased sensitivity to furosemide. [40]

Pharmacokinetics

The pharmacokinetics of furosemide are not significantly altered by food. [51]

No direct relationship has been found between furosemide concentration in the plasma and furosemide efficacy. Efficacy depends upon the concentration of furosemide in urine. [27]

Names

Furosemide is the INN and BAN. [52] The previous BAN was frusemide.

Brand names under which furosemide is marketed include Aisemide, Apo-Furosemide, Beronald, Desdemin, Discoid, Diural, Diurapid, Dryptal, Durafurid, Edemid, Errolon, Eutensin, Farsiretic, Flusapex, Frudix, Frusemide, Frusetic, Frusid, Fulsix, Fuluvamide, Furantril, Furesis, Furix, Furo-Puren, Furon, Furosedon, Fusid.frusone, Hydro-rapid, Impugan, Katlex, Lasilix, Lasix, Lodix, Lowpston, Macasirool, Mirfat, Nicorol, Odemase, Oedemex, Profemin, Rosemide, Rusyde, Salix, Seguril, Teva-Furosemide, Trofurit, Uremide, and Urex.

Veterinary uses

Furosemide for feline use Furosemide for veterinary use.jpg
Furosemide for feline use

The diuretic effects are put to use most commonly in horses to prevent bleeding during a race. In the United States of America, under the racing rules of most states, horses that bleed from the nostrils (exercise-induced pulmonary hemorrhage) three times are permanently barred from racing. Sometime in the early 1970s, furosemide's ability to prevent, or at least greatly reduce, the incidence of bleeding by horses during races was discovered accidentally. Clinical trials followed, and by the decade's end, racing commissions in some states in the USA began legalizing its use on race horses. In 1995, New York became the last state in the United States to approve such use, after years of refusing to consider doing so. [53] Some states allow its use for all racehorses; some allow it only for confirmed "bleeders". Its use for this purpose is still prohibited in many other countries.[ citation needed ]

Furosemide is also used in horses for pulmonary edema, congestive heart failure (in combination with other drugs), and allergic reactions. Although it increases circulation to the kidneys, it does not help kidney function and is not recommended for kidney disease. [54]

It is also used to treat congestive heart failure (pulmonary edema, pleural effusion, and/or ascites) in cats and dogs. [55]

Horses

Furosemide is injected either intramuscularly or intravenously, usually 0.5-1.0 mg/kg twice/day, although less before a horse is raced. As with many diuretics, it can cause dehydration and electrolyte imbalance, including loss of potassium, calcium, sodium, and magnesium. Excessive use of furosemide will most likely lead to a metabolic alkalosis due to hypochloremia and hypokalemia. The drug should, therefore, not be used in horses that are dehydrated or experiencing kidney failure. It should be used with caution in horses with liver problems or electrolyte abnormalities. Overdose may lead to dehydration, change in drinking patterns and urination, seizures, gastrointestinal problems, kidney damage, lethargy, collapse, and coma.

Furosemide should be used with caution when combined with corticosteroids (as this increases the risk of electrolyte imbalance), aminoglycoside antibiotics (increases the risk of kidney or ear damage), and trimethoprim sulfa (causes decreased platelet count). It may also cause interactions with anesthetics, so its use should be related to the veterinarian if the animal is going into surgery, it decreases the kidneys' ability to excrete aspirin, so dosages will need to be adjusted if combined with that drug.

Furosemide may increase the risk of digoxin toxicity due to hypokalemia.

It is recommended that furosemide not be used during pregnancy or in a lactating mare, as it is passed through the placenta and milk in studies with other species. It should not be used in horses with pituitary pars intermedia dysfunction (Equine Cushing's Disease).

Furosemide is detectable in urine 36–72 hours following injection. Its use is restricted by most equestrian organizations.

US major racetracks ban the use of furosemide on race days. [56]

Related Research Articles

<span class="mw-page-title-main">Ascites</span> Abnormal build-up of fluid in the abdomen

Ascites is the abnormal build-up of fluid in the abdomen. Technically, it is more than 25 ml of fluid in the peritoneal cavity, although volumes greater than one liter may occur. Symptoms may include increased abdominal size, increased weight, abdominal discomfort, and shortness of breath. Complications can include spontaneous bacterial peritonitis.

<span class="mw-page-title-main">Acetazolamide</span> Chemical compound

Acetazolamide, sold under the trade name Diamox among others, is a medication used to treat glaucoma, epilepsy, acute mountain sickness, periodic paralysis, idiopathic intracranial hypertension, heart failure and to alkalinize urine. It may be used long term for the treatment of open angle glaucoma and short term for acute angle closure glaucoma until surgery can be carried out. It is taken by mouth or injection into a vein. Acetazolamide is a first generation carbonic anhydrase inhibitor and it decreases the ocular fluid and osmolality in the eye to decrease intraocular pressure.

<span class="mw-page-title-main">Hydrochlorothiazide</span> Diuretic medication

Hydrochlorothiazide, sold under the brand name Hydrodiuril among others, is a diuretic medication used to treat hypertension and swelling due to fluid build-up. Other uses include treating diabetes insipidus and renal tubular acidosis and to decrease the risk of kidney stones in those with a high calcium level in the urine. Hydrochlorothiazide is taken by mouth and may be combined with other blood pressure medications as a single pill to increase effectiveness. Hydrochlorothiazide is a thiazide medication which inhibits reabsorption of sodium and chloride ions from the distal convoluted tubules of the kidneys, causing a natriuresis. This initially increases urine volume and lowers blood volume. It is believed to reduce peripheral vascular resistance.

Antihypertensives are a class of drugs that are used to treat hypertension. Antihypertensive therapy seeks to prevent the complications of high blood pressure, such as stroke, heart failure, kidney failure and myocardial infarction. Evidence suggests that reduction of the blood pressure by 5 mmHg can decrease the risk of stroke by 34% and of ischaemic heart disease by 21%, and can reduce the likelihood of dementia, heart failure, and mortality from cardiovascular disease. There are many classes of antihypertensives, which lower blood pressure by different means. Among the most important and most widely used medications are thiazide diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers or antagonists (ARBs), and beta blockers.

<span class="mw-page-title-main">Electrolyte imbalance</span> Abnormality in the concentration of electrolytes in the body

Electrolyte imbalance, or water-electrolyte imbalance, is an abnormality in the concentration of electrolytes in the body. Electrolytes play a vital role in maintaining homeostasis in the body. They help to regulate heart and neurological function, fluid balance, oxygen delivery, acid–base balance and much more. Electrolyte imbalances can develop by consuming too little or too much electrolyte as well as excreting too little or too much electrolyte. Examples of electrolytes include calcium, chloride, magnesium, phosphate, potassium, and sodium.

<span class="mw-page-title-main">Hypokalemia</span> Insufficient potassium in the blood

Hypokalemia is a low level of potassium (K+) in the blood serum. Mild low potassium does not typically cause symptoms. Symptoms may include feeling tired, leg cramps, weakness, and constipation. Low potassium also increases the risk of an abnormal heart rhythm, which is often too slow and can cause cardiac arrest.

<span class="mw-page-title-main">Loop diuretic</span> Diuretics that act along the loop of Henle in the kidneys

Loop diuretics are pharmacological agents that primarily inhibit the Na-K-Cl cotransporter located on the luminal membrane of cells along the thick ascending limb of the loop of Henle. They are often used for the treatment of hypertension and edema secondary to congestive heart failure, liver cirrhosis, or chronic kidney disease. While thiazide diuretics are more effective in patients with normal kidney function, loop diuretics are more effective in patients with impaired kidney function.

<span class="mw-page-title-main">Amiloride</span> Medication

Amiloride, sold under the trade name Midamor among others, is a medication typically used with other medications to treat high blood pressure or swelling due to heart failure or cirrhosis of the liver. Amiloride is classified as a potassium-sparing diuretic. Amiloride is often used together with another diuretic, such as a thiazide or loop diuretic. It is taken by mouth. Onset of action is about two hours and it lasts for about a day.

<span class="mw-page-title-main">Chlortalidone</span> Thiazide-like diuretic drug

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<span class="mw-page-title-main">Thiazide</span> Class of chemical compounds

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<span class="mw-page-title-main">Potassium-sparing diuretic</span> Drugs that cause diuresis without causing potassium loss in the urine and leading to hyperkalemia

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<span class="mw-page-title-main">Etacrynic acid</span> Chemical compound

Etacrynic acid (INN) or ethacrynic acid (USAN), trade name Edecrin, is a loop diuretic used to treat high blood pressure and the swelling caused by diseases like congestive heart failure, liver failure, and kidney failure. A con with ethacrynic acid compared to the other loop diuretic drugs such as furosemide is that it has a significantly steep dose-response curve, which means the drug's dosing is very important as small variance in dose can cause a significant difference in the biological response.

<span class="mw-page-title-main">Metolazone</span> Chemical compound

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<span class="mw-page-title-main">Torasemide</span> Diuretic medication

Torasemide, also known as torsemide, is a diuretic medication used to treat fluid overload due to heart failure, kidney disease, and liver disease. It is a less preferred treatment for high blood pressure. It is taken by mouth or by injection into a vein.

<span class="mw-page-title-main">Chlorothiazide</span> Chemical compound

Chlorothiazide, sold under the brand name Diuril among others, is an organic compound used as a diuretic and as an antihypertensive.

<span class="mw-page-title-main">Acute decompensated heart failure</span> Medical condition

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QT prolongation is a measure of delayed ventricular repolarisation, which means the heart muscle takes longer than normal to recharge between beats. It is an electrical disturbance which can be seen on an electrocardiogram (ECG). Excessive QT prolongation can trigger tachycardias such as torsades de pointes (TdP). QT prolongation is an established side effect of antiarrhythmics, but can also be caused by a wide range of non-cardiac medicines, including antibiotics, antidepressants, antihistamines, opioids, and complementary medicines. On an ECG, the QT interval represents the summation of action potentials in cardiac muscle cells, which can be caused by an increase in inward current through sodium or calcium channels, or a decrease in outward current through potassium channels. By binding to and inhibiting the “rapid” delayed rectifier potassium current protein, certain drugs are able to decrease the outward flow of potassium ions and extend the length of phase 3 myocardial repolarization, resulting in QT prolongation.

<span class="mw-page-title-main">Diuretic</span> Substance that promotes the production of urine

A diuretic is any substance that promotes diuresis, the increased production of urine. This includes forced diuresis. A diuretic tablet is sometimes colloquially called a water tablet. There are several categories of diuretics. All diuretics increase the excretion of water from the body, through the kidneys. There exist several classes of diuretic, and each works in a distinct way. Alternatively, an antidiuretic, such as vasopressin, is an agent or drug which reduces the excretion of water in urine.

<span class="mw-page-title-main">Ototoxic medication</span>

Ototoxicity is defined as the toxic effect on the functioning of the inner ear, which may lead to temporary or permanent hearing loss (cochleotoxic) and balancing problems (vestibulotoxic). Drugs or pharmaceutical agents inducing ototoxicity are regarded as ototoxic medications.

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