1. ד"ר בלמור ג'ינג'י פנימית ב תל השומר
חשיבותו של ה(מ)שתן
ד"ר בלמור ג'ינג'י
פנימית ב תל השומר

2. Questions Guidelines for Furosemide route and dosing?
Should we give Furosemide during oliguric tubular necrosis?
Alternative drug over Furosemide?

3. Furosemide - Contraindications
Hypersensitivity
Anuria

4. Furosemide - Dosing - Micromedex
Congestive heart failure
a) Initial, 20 to 80 mg ORALLY daily, may repeat in 6 to 8 hours; MAX 600 mg/day ORALLY
b) Initial, 20 to 40 mg IV over 1 to 2 min;
c) IV infusion, administer at a rate not greater than 4 mg/min
(Prod Info furosemide injection, 2001)

5. Furosemide - Dosing - Route
In severe congestive heart failure, a continuous infusion is more effective than intravenous bolus. In a randomized study comparing intermittent to continous drip (250 to 2000 milligrams), the continuous infusion caused excretion of a significantly higher volume of urine.

6. Furosemide - Dosage in Renal Failure
Dosage adjustment is not required in patients with renal failure. Patients may require higher than usual doses to induce diuresis The manufacturer recommends a maximum daily intravenous dose of 2000 mg. Doses of up to 3200 mg/day have been used in patients with severe renal failure.
higher

7. Furosemide - Dosage During Dialysis
  No specific dosage adjustment of furosemide is necessary for dialysis patients.

8. Furosemide - Dosing - martindale
Patients have been successfully treated using
continuous intravenous infusions or high doses
(up to 8 g daily) of furosemide given by intravenous
infusion or orally.

9. "Fat Man's Laws of the House of God. by Samuel Shem,
GOMERS DON’T DIE.
GOMERS GO TO GROUND.
AT A CARDIAC ARREST, THE FIRST PROCEDURE IS TO TAKE YOUR OWN PULSE.
THE PATIENT IS THE ONE WITH THE DISEASE.
PLACEMENT COMES FIRST.
THERE IS NO BODY CAVITY THAT CANNOT BE REACHED WITH A #14 NEEDLE AND A GOOD STRONG ARM.
AGE + BUN (Blood Urea Nitrogen) = LASIX DOSE.
THEY CAN ALWAYS HURT YOU MORE.
THE ONLY GOOD ADMISSION IS A DEAD ADMISSION.
IF YOU DON’T TAKE A TEMPERATURE, YOU CAN’T FIND A FEVER.
SHOW ME A MEDICAL STUDENT WHO ONLY TRIPLES MY WORK AND I WILL KISS HIS FEET.
IF THE RADIOLOGY RESIDENT AND THE MEDICAL STUDENT BOTH SEE A LESION ON THE CHEST X-RAY, THERE CAN BE NO LESION THERE.
THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.

10. "Fat Man's Laws of the House of God. by Samuel Shem 7
"Fat Man's Laws of the House of God. by Samuel Shem 7. LASIX DOSE = AGE + BUN (Blood Urea Nitrogen)

11. Furosemide - ADME
Oral Absorption - tablets and solution: 47% to 70%

12. Furosemide - Adverse Effects
Hypokalemia
Hypomagnesemia
Metabolic alkalosis
Hyperuricemia
Hypocalcemia

13. Furosemide - Adverse Effects
Hyperglycemia
Like thiazide, furosemide causes increased glucose levels. Hyperglycemia usually presents after 2 to 4 weeks of treatment.
Lipids
increases in serum lipid levels

14. Furosemide - Adverse Effects
Vitamin deficiency
long-term (3 to 14 months) treatment may be associated with clinically significant thiamine deficiency due to excessive urinary excretion of thiamine.

15. Furosemide - Adverse Effects
Agranulocytosis  
Aplastic anemia
Thrombocytopenia

16. Furosemide - Adverse Effects
Osteopenia
Hip fracture 

17. Furosemide - Adverse Effects
Erythema multiforme
as early as within 4 days of therapy and as late as 18 months.
Stevens-Johnson syndrome

18. Furosemide - Adverse Effects

19. Furosemide - Ototoxicity
Ototoxicity in most cases it is reversible. Predisposing risk factors include high doses, renal, cardiac, or liver impairment, hypoproteinemia, and concomitant administration of other ototoxic drugs. The Adverse Drug Reaction Reporting Program sponsored by the FDA reported 29 cases of deafness attributed to furosemide. Total doses ranged from 40 mg to 21.6 g with 3 patients suffering permanent hearing loss. In most patients, hearing loss was transient, lasting 1/2 hour to 24 hours.

20. Furosemide - Ototoxicity Prevention
1)continuous slow IV infusion 2) combinations of aminoglycoside antibiotics and furosemide should be avoided 3) divided oral dose regimens;

21. Furosemide- Adverse Effects
Proteinuria
Nephrotoxicity
Chronic tubulointerstitial nephritis and distal renal tubular acidosis were reported in a 25-year-old woman who was abusing furosemide. The patient had been taking furosemide 40 to 80 mg/day for cyclic edema, without a physician's prescription. She gradually increased the dose. 15 days before presentation, she stopped the diuretic; at that time, she was ingesting 1.2 grams/day. Renal biopsy showed tubular cell atrophy with flattened epithelial cells, interstitial fibrosis, and areas of mononuclear cell infiltration in the interstitium.

22. Continous infusion versus bolus injection of loop diuretics in CHF
The cochrane collaboration
First version – 2003 update

23. Furosemide – Cochrane review
Intermittent administration of furosemide vs continuous infusion preceded by a loading dose for congestive heart failure. Lahav M, Regev A, Ra’anani P, Theodor E. Chest 1992;102:725–31.

24. Continuous Infusion vs
Continuous Infusion vs. Bolus Injection Outcome : Total urine output (cc in 24 hour)

25. Continuous Infusion vs. Bolus Injection, Outcome : All Cause Mortality

26. Continuous Infusion vs
Continuous Infusion vs. Bolus Injection, Outcome :Tinnitus and Hearing Loss.

27. Continuous Infusion vs
Continuous Infusion vs. Bolus Injection, Outcome : Increase in Serum Creatinine Levels

28. Meta-analysis of frusemide to prevent or treat acute renal failure.
Ho KM, Sheridan DJ
BMJ Aug 26;333(7565):420

30. Furosemide for acute renal failure
Outcome measures not significantly different after furosemide treatment were in-hospital mortality, dialysis, number of dialysis sessions required, and proportion of patients with persistent oliguria.
Evidence suggested an increased risk of temporary deafness and tinnitus in patients treated with high doses of frusemide (relative risk 3.97).

31. Furosemide for acute renal failure
Conclusions Frusemide is not associated with any significant clinical benefits in the prevention and treatment of acute renal failure in adults. High doses may be associated with an increased risk of ototoxicity.

32. Questions Guidelines for Furosemide route and dosing?
Should we give Furosemide during oliguric tubular necrosis?
Alternative drug over Furosemide?
Should we start a study on Furosemide?