Diuretics

Oral
.
Initial dose
Target dose
Maximal dose
Loop Diuretics.

Furosamide (Lasix)
20-40 mg qd
as needed
240 mg bid

Bumetanide (Bumex)
0.5-1.0 mg qd
as needed
10 mg qd

Torsemide (Demedex)
10-20 mg qd
as needed
80-120 mg bid
Thiazide Diuretics.

Hydrochlorothiazide
25-50 mg qd
as needed
100-200 mg qd
Thiazide-Related Diuretics.

Metolazone (Zaroxolyn) (a)
2.5-5.0 mg qd
2.5-5.0 mg 2-3 time/wk
10 mg qd
(a) = Metolazone may cause significant electrolyte imbalance.

IV Bolus
.
Dose depending on Creatinine Clearance
Dose Frequency
Furosamide (Lasix)
>40 mg ------ 160-240 mg
q 8 hrs, q 12 hrs
Bumetanide (Bumex)
>2 mg ------
q 12 hrs
Torsemide (Demedex)
10-20 mg ------ 100 mg
q 12 hrs

IV Infusion
.
Loading Dose (mg)
Infusion Rate (mg/hr)
CrCl >75 ml/min
CrCl 25-75 ml/min
CrCl <25 ml/min
Furosamide (Lasix) (a)
40
10
10-20
20-40
Bumetanide (Bumex)
1
0.5
0.5-1
1-2
Torsemide (Demedex)
20
5
5-10
10-20

Diuretic Refractory
1. Medication noncompliance, excessive salt and fluid intake and NSAIDs are the common reasons that the patients become refractory to diuretics.
2. Prescribe higher loop diuretic dose. Avoid single daily dose to decrease post diuretic sodium retention (Furosamide has short half life).
3. Oral Torsemide has better absorption and bioavailability than Furosemide in symptomatic HF with fluid retention.
4. Combine diuretics with different sites of action i.e... Metolazone (give 1/2 hour before) and Furosamide/Bumetanide/Torsamide. Use lowest effective Metolazone i.e.. 2.5-5.0 mg 2-3 times/week or prn per weight increase. For IV use, prescribe Chlorothiazide or hydrochlorothiazide 250-500 mg or 25-50 mg respectively, 1/2 hour before IV loop diuretic. Monitor electrolyte when use Metolazone.
5. Intravenous loop diuretics, bolus. May be used as outpatient.
6. Intravenous loop diuretics, continuous infusion, is more effective and requires less total daily dose than bolus form.
7. Combine diuretics and drugs that increase renal blood flow, i.e... Dobutamine, Milronone, Nesiritide, low dose Dopamine.
8. Ultrafiltration.