Drug Information request:
Question: Furosemide infusion versus high dose bolus for management
of diuretic resistant CHF
Patients with diuretic resistance (requiring doses of >250mg/day of furosemide) may benefit
from a continuous infusion of furosemide as compared to high bolus dosing twice daily. It is
proposed that with a continuous infusion, there is better drug delivery to the proximal tubule and
loop of Henle as well as decreased incidence of ototoxicity. In addition, there may be less
rebound sodium retention with a continuous infusion as opposed to time between high bolus
dosing.
Upon reviewing the available literature in this topic, it is generally considered that a continuous
IV infusion of furosemide provides better diuresis than that achieved with high bolus dosing.
There is no difference with regard to mortality data in any of the available studies.
In the case of patient B.C, he is currently receiving 200 mg IV q 12h with less than adequate
diuresis. There are two methods described in the literature to provide a continuous infusion:
Method 1:
Initiate a continuous furosemide infusion starting at ranging from 4 -20 mg/hr. The
absolute maximum recommended dose is 160 mg/hr or 4000mg/24 hours.
Method 2:
Calculate current total daily dose of furosemide – then give 20% as a bolus followed by
an infusion of 10% of dose/hr for 8 hours. Repeat this procedure daily.
Recommendation:
Have patient reassessed by Home IV therapy RN to start furosemide infusion at 10 mg/hr and
gradually increasing to 20 mg/hr. The pharmacy department will supply an IV solution of
furosemide at a concentration of 3mg/ml (300mg in 100ml sodium chloride 0.9% solution).
Monitoring parameters for furosemide infusion:
1. Daily weights recorded by patient or RN
2. SCr and electrolytes 3x per week for first week of therapy
3. For the first three days, have patient return to hospital for initial assessment, if stable may
decrease assessments to twice weekly.
CIVA instructions:
Conc.:
3mg/ml in Sodium Chloride 0.9% (i.e. 300mg in 100mg)
○
Stability:
Room Temp. (22 C) for at least 7 days, must be protected from light at all times
May be administered in lactated ringers, but stability is 24 hours at maximum concentration of 1
mg/ml)
Thank you,
Jody Smith
Clinical Pharmacist
MSA Hospital
January 2006
References:
1. Micromedex 2004
2. 2. Sunnybrook IV Manual. www.icom.ca/shsc/ivmono/furosei.html
3. Salvador DRK, Rey NR, Ramos GC, Punzalan FER. Continuous infusion versus bolus
injection of loop diuretics in congestive heart failure. Cochrane Database of Systematic
Reviews. 2004;4.
4. Dormans TP, van Meyel JJM, et al. Diuretic efficacy of high dose furosemide in severe
heart failure: bolus injection versus continuous infusion. J Am Coll Cardiol 1996;28:37682.
5. Trissel LA, ed. Handbook on Injectable Drugs, 13th ed. 2005:691-692.