Name of the Loop Diuretics high ceiling Drugs
- Furosemide
- Bumetanide
- Torsemide
1.Furosemide
| Furosemide |
| Availability Injection: 10 mg/ml Oral solution: 10 mg/ml, 40 mg/5 ml Tablets: 20 mg, 40 mg, 80 mg |
| Indications and dosages ➣ Acute pulmonary edema Adults: 40 mg I.V. given over 1 to 2 minutes. If adequate response doesn’t occur within 1 hour, give 80 mg I.V. over 1 to 2 minutes. ➣ Edema caused by heart failure, hepatic cirrhosis, or renal disease Adults: Initially, 20 to 80 mg/day P.O. as a single dose; may increase in 20- to 40-mg increments P.O. q 6 to 8 hours until desired response occurs. Thereafter, may give once or twice daily. For maintenance, dosage may be reduced in some patients or carefully titrated upward to 600 mg P.O. daily in severe edema. Usual I.M. or I.V. dosage is 20 to 40 mg as a single injection; if response inadequate, second and each succeeding dose may be increased in 20-mg increments and given no more often than q 2 hours until desired response occurs. Single dose may then be given once or twice daily. Infants and children: 2 mg/kg P.O. (oral solution) as a single dose. As necessary, increase in increments of 1 or 2 mg/kg q 6 to 8 hours to a maximum of 6 mg/kg/dose. For maintenance, give minimum effective dosage. ➣ Hypertension Adults: 40 mg P.O. b.i.d. If satisfactory response doesn’t occur, other antihypertensives may be added before furosemide dosage is increased. However, dosage may be titrated upward as needed and tolerated to a maximum of 240 mg P.O. daily in two or three divided doses. |
Mechanism of Action
Inhibits sodium and water reabsorption in the loop of Henle and increases urine formation. As the body’s plasma volume decreases, aldosterone production increases, which promotes sodium reabsorption and the loss of potassium and hydrogen ions. Furosemide also increases the excretion of calcium, magnesium, bicarbonate, ammonium, and phosphate. By reducing intracellular and extracellular fluid volume, the drug reduces blood pressure and decreases cardiac output. Over time, cardiac output returns to normal.
Pharmacokinetics
- Bioavailability: 47-64% (PO); 79% (premature infants)
- Protein bound: 91-99%
- Metabolized in liver (~10%)
- Half-life: 30-120 min (normal renal function); 9 hr (end-stage renal disease)
- Excretion: Urine (PO, 50%; IV, 80%)
Administration
- Know that I.V. or I.M. injection is given when patient requires rapid onset of diuresis or can’t receive oral doses.
- Be aware that I.V. dose may be given by direct injection over 1 to 2 minutes.
- For I.V. infusion, dilute in dextrose 5% in water, normal saline solution, or lactated Ringer’s solution.
- Don’t infuse more than 4 mg/ minute.
- Give oral doses in morning with food. If second dose is prescribed, give in afternoon.
Contraindications
- Hypersensitivity to drug or other sulfonamides
- Anuria
Precautions :
- Diabetes mellitus, severe hepatic disease
- Elderly patients
- Pregnant or breastfeeding patients
- Neonate
Adverse reactions
- CNS: dizziness, headache, vertigo, weakness, lethargy, paresthesia, drowsiness, restlessness, light-headedness
- CV: hypotension, orthostatic hypotension, tachycardia, volume depletion, necrotizing angiitis, thrombophlebitis, arrhythmias
- EENT: blurred vision, xanthopsia, hearing loss, tinnitus
- GI: nausea, vomiting, diarrhea, constipation, dyspepsia, oral and gastric irritation, cramping, anorexia, dry mouth, acute pancreatitis
- GU: excessive and frequent urination, nocturia, glycosuria, bladder spasm, oliguria, interstitial nephritis
- Hematologic: anemia, purpura, leukopenia, thrombocytopenia, hemolytic anemia
- Hepatic: jaundice
- Metabolic: hyperglycemia, hyperuricemia, dehydration, hypokalemia, hypomagnesemia, hypocalcemia, hypochloremic alkalosis
- Musculoskeletal: muscle pain, muscle cramps
- Skin: photosensitivity, rash, diaphoresis, urticaria, pruritus, exfoliative dermatitis, erythema multiforme
- Other: fever, transient pain at I.M. injection site
Patient monitoring
- Watch for signs and symptoms of ototoxicity.
- Assess for other evidence of drug toxicity (arrhythmias, renal dysfunction, abdominal pain, sore throat, fever).
- Monitor CBC, BUN, and electrolyte, uric acid, and CO2 levels.
- Monitor blood pressure, pulse, fluid intake and output, and weight.
- Assess blood glucose levels in patients with diabetes mellitus.
- Monitor dietary potassium intake. Watch for signs and symptoms of hypokalemia.
Patient teaching
- Instruct patient to take in morning with food (and second dose, if prescribed, in afternoon), to prevent nocturia.
- Tell patient that drug may cause serious interactions with many common drugs. Instruct him to tell all prescribers he’s taking it.
- Instruct patient to report signs and symptoms of ototoxicity (hearing loss, ringing in ears, vertigo) and other drug toxicities.
- Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration and alertness.
- Instruct patient to move slowly when rising, to avoid dizziness from sudden blood pressure decrease.
- Encourage patient to discuss need for potassium and magnesium supplements with prescriber.
- Caution patient to avoid alcohol and herbs while taking this drug.
- Inform patient that he’ll undergo regular blood testing during therapy.
- As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, herbs, and behaviors mentioned above.
Nursing Considerations
- Obtain patient’s weight before and periodically during furosemide therapy to monitor fluid loss.
- For once-a-day dosing, give drug in the morning so patient’s sleep won’t be interrupted by increased need to urinate.
- Prepare drug for infusion with normal saline solution, lactated Ringer’s solution, or D5W.
- Administer drug slowly I.V. over 1 to 2 minutes to prevent ototoxicity.
- Expect patient to have periodic hearing tests during prolonged or high-dose I.V. therapy.
- Monitor blood pressure and hepatic and renal function as well as BUN, blood glucose, and serum creatinine, electrolyte, and uric acid levels, as appropriate.
- Be aware that elderly patients are more susceptible to hypotensive and electrolytealtering effects and thus are at greater risk for shock and thromboembolism.
- If patient is at high risk for hypokalemia, give potassium supplements along with furosemide, as prescribed.
- Expect to discontinue furosemide at maximum dosage if oliguria persists for more than 24 hours.
- Be aware that furosemide may worsen left ventricular hypertrophy and adversely affect glucose tolerance and lipid metabolism. • Notify prescriber if patient experiences hearing loss, vertigo, or ringing, buzzing, or sense of fullness in her ears. Drug may need to be discontinued
2.Bumetanide
| Bumetanide |
| Availability Injection: 0.25 mg/ml Tablets: 0.5 mg, 1 mg, 2 mg |
| Indications and dosages ➣ Edema caused by heart failure or hepatic or renal disease; adult nocturia Adults: 0.5 to 2 mg/day P.O. as a single dose; up to two additional doses may be given q 4 to 5 hours (up to 10 mg/ day). Or 0.5 to 1 mg I.V. or I.M., repeated q 2 to 3 hours as needed, up to 10 mg/day. ➣ Hypertension Adults: 0.5 mg/day P.O. Maximum dosage is 5 mg/day. |
Mechanism of Action
Inhibits reabsorption of sodium, chloride, and water in the ascending limb of the loop of Henle, which promotes their excretion and reduces fluid volume.
Pharmacokinetics
- Bioavailability: 59-89%
- Peak plasma time: IV, 5 min; IM, 30 min; PO, 1-2 hr
- Protein bound: 94-96%
- Partially metabolized in liver
- Half-life: Adults, 1-1.5 hr; infants >1 month, 2.4 hr; neonates, 6 hr
- Excretion: Urine (81%), feces (2%)
Administration
- Know that oral or I.V. route is preferred, because I.M. administration may cause pain at injection site.
- Be aware that drug may be given alone or with other antihypertensives.
- Dilute with dextrose 5% in water, normal saline solution, or lactated Ringer’s injection.
- Give I.V. dose slowly over 2 minutes.
- Give P.O. form with food or milk.
Contraindications
- Hypersensitivity to drug or sulfonamides
- Uncorrected electrolyte imbalances
- Hepatic coma
- Anuria and oliguria
Precautions :
- Severe hepatic disease, electrolyte depletion, diabetes mellitus, worsening azotemia
- Elderly patients
- Pregnant or breastfeeding patients
- Children younger than age 18.
Adverse reactions
- CNS: dizziness, headache, insomnia, nervousness, vertigo, weakness, paresthesia, confusion, fatigue, hand-flapping tremor, encephalopathy
- CV: hypotension, ECG changes, chest pain, thrombophlebitis, arrhythmias
- EENT: blurred vision, nystagmus, hearing loss, tinnitus
- GI: nausea, vomiting, diarrhea, constipation, dyspepsia, gastric irritation, dry mouth, anorexia, acute pancreatitis
- GU: polyuria, nocturia, glycosuria, premature ejaculation, difficulty maintaining erection, oliguria, renal failure
- Hepatic: jaundice
- Metabolic: dehydration, hyperglycemia, hyperuricemia, hypokalemia, hypomagnesemia, hypochloremic alkalosis
- Musculoskeletal: arthralgia; muscle cramps, aching, or tenderness
- Skin: photosensitivity, hives, rash, pruritus, urticaria, diaphoresis
- Other: pain, nipple tenderness
Patient monitoring
- Weigh patient at start of therapy and monitor weight throughout therapy.
- Monitor blood pressure regularly.
- Monitor serum electrolyte, uric acid, glucose, and BUN levels.
- Monitor elderly patients for extreme blood pressure changes, orthostatic hypotension, and dehydration
Patient teaching
- Advise patient to take drug in morning to prevent nocturia, and to take second dose (if required) in late afternoon.
- Instruct patient to move slowly when sitting up or standing, to avoid dizziness or light-headedness from sudden blood pressure drop.
- Caution patient to avoid alcohol because of increased risk of hypotension.
- Advise patient to eat foods high in potassium. Provide other dietary counseling as appropriate to help prevent or minimize electrolyte imbalances.
- Instruct patient to weigh himself often to help detect fluid retention.
- As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, herbs, and behaviors mentioned above.
Nursing Considerations
- Expect to use parenteral route for patients with impaired GI absorption or in whom the oral route isn’t practical. Switch to oral route, as prescribed, as soon as possible.
- Discard unused parenteral solution 24 hours after preparation.
- Assess fluid and electrolyte balance closely because bumetanide is a potent diuretic (40 to 60 times more potent than furosemide). Monitor fluid intake and output once every 8 hours, evaluate serum electrolyte levels when ordered, and assess for imbalances.
- Monitor serum potassium level regularly to check for hypokalemia, especially if patient takes a digitalis glycoside for heart failure or has hepatic cirrhosis, ascites, aldosteronism, potassium-losing nephropathy, diarrhea, or a history of ventricular arrhythmias.
- Assess for evidence of ototoxicity, such as tinnitus, daily. Rarely, drug may cause ototoxicity, especially with I.V. use, high doses, and increased frequency of dosing in a patient with renal impairment.
- Monitor results of renal function tests during therapy to detect adverse reactions.
3.Torsemide
| Availability Injection: 10 mg/ml Tablets: 5 mg, 10 mg, 20 mg, 100 mg |
| Indications and dosages ➣ Heart failure Adults: 10 to 20 mg P.O. or I.V. daily. If response inadequate, double dosage until desired response occurs. Don’t exceed 200 mg as a single dose. ➣ Hypertension Adults: 5 mg P.O. daily. May increase to 10 mg daily after 4 to 6 weeks; if drug still isn’t effective, additional antihypertensives may be prescribed. ➣ Chronic renal failure Adults: 20 mg P.O. or I.V. daily. If response inadequate, double dosage until desired response occurs. Don’t exceed 200 mg as a single dose. ➣ Hepatic cirrhosis Adults: 5 or 10 mg P.O. or I.V. daily, given with aldosterone antagonist or potassium-sparing diuretic. If response inadequate, double dosage. Don’t exceed 40 mg as a single dose. |
Mechanism of Action
Blocks active sodium and chloride reabsorption in the ascending loop of Henle by promoting rapid excretion of water, sodium, and chloride. Torsemide also increases the production of renal prostaglandins, increasing the plasma renin level and renal vasodilation. As a result, blood pressure falls, reducing preload and afterload.
Pharmacokinetics
- Bioavailability: 80%
- Peak plasma time: 2.5 hr (Soaanz); 1 hr (generic)
- Protein bound: >99%
- Metabolized in liver by CYP2C9 (major), CYP2C8 (minor), CYP2C18 (minor)
- Half-life: 3.5 hr
- Excretion: Urine (21% [torsemide]; 12% [M1]; 2% [M3]; 34% [M5])
Administration
- Give I.V. by direct injection over at least 2 minutes or by continuous I.V. infusion.
- Flush I.V. line with normal saline solution before and after administering
Contraindications
- Severe hepatic disease accompanied by cirrhosis or ascites, preexisting uncorrected electrolyte imbalances, diabetes mellitus, worsening azotemia
- Elderly patients
- Pregnant or breastfeeding patients
- Children younger than age 18.
Adverse reactions
- CNS: dizziness, headache, asthenia, insomnia, nervousness, syncope
- CV: hypotension, ECG changes, chest pain, volume depletion, atrial fibrillation, ventricular tachycardia, shunt thrombosis
- EENT: rhinitis, sore throat
- GI: nausea, diarrhea, vomiting, constipation, dyspepsia, anorexia, rectal bleeding, GI hemorrhage
- GU: excessive urination Metabolic: hyperglycemia, hyperuricemia, hypokalemia
- Musculoskeletal: joint pain, myalgia
- Respiratory: increased cough
- Skin: rash
- Other: edema
Patient monitoring
- Monitor vital signs, especially for hypotension.
- Assess ECG for arrhythmias and other changes.
- Monitor weight and fluid intake and output to assess drug efficacy.
- Monitor electrolyte levels, particularly potassium. Stay alert for signs and symptoms of hypokalemia.
- Assess hearing for signs and symptoms of ototoxicity.
- Monitor blood glucose level carefully in diabetic patient.
Patient teaching
- Advise patient to take in morning with or without food.
- Instruct patient to move slowly when sitting up or standing, to avoid dizziness from sudden blood pressure drop
- Tell patient to monitor weight and report sudden increases.
- Instruct diabetic patient to monitor blood glucose level carefully.
- Caution patient to avoid alcohol during drug therapy.
- Advise patient to consult prescriber before using herbs.
- As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, herbs, and behaviors mentioned above.
Nursing Considerations
- Inject I.V. torsemide slowly over 2 minutes. Flush I.V. line with normal saline solution before and afterward.
- Don’t exceed 200 mg in a single I.V. dose of torsemide.
- Monitor patient’s serum electrolyte levels and fluid intake and output to detect hypovolemia.
REFERENCES
- Robert Kizior, Keith Hodgson, Saunders Nursing Drug handbook,1st edition 2024, Elsevier Publications. ISBN-9780443116070
- McGraw Hill- Drug Handbook, Seventh Edition, 2013, McGraw Hill Education Publications,9780071799430.
- April Hazard, Cynthia Sanoski, Davi’s Drug Guide for Nurses -Sixteenth Edition 2019, FA Davis Company Publications,9780803669451.
- Jones and Bartlet, Pharmacology for Nurses, Second Edition, 2020, Jones and Bartlet Learning Publications, ISBN 9781284141986.
- Nursebro.com, Search – Nursebro
Stories are the threads that bind us; through them, we understand each other, grow, and heal.
JOHN NOORD
Connect with “Nurses Lab Editorial Team”
I hope you found this information helpful. Do you have any questions or comments? Kindly write in comments section. Subscribe the Blog with your email so you can stay updated on upcoming events and the latest articles.
