Diuretic Dosing in Edema

Furosemide (Lasix®) [UpToDate] [LPCH Lexicomp]

• Enteral 💊/🧪

  • Preemies: 1-2 mg/kg q12-24h

    • Avoid doses ≥2 mg/kg/day in patients ≤31 weeks adjusted (↑ risk of ototoxicity 👂☠)

  • Neonates: 1-2 mg/kg q6-8h

  • Children: 1-2 mg/kg q6-24h

    • Max 6 mg/kg/dose (≤200 mg/dose, ≤10 mg/kg/day)

  • Adults: 20-80 mg/dose q6-8h

    • Titrate by 20-40 mg q6-8h

    • Max 200 mg/dose (≤600 mg/day)

  • Note: onset of diuresis 30-60 mins, with peak in 1-2 hours and duration of 6-8 hours

• Intravenous (IV)

  • Intermittent 💉/💪

    • Preemies: 0.5-1 mg/kg/dose q12-24h

      • Avoid doses ≥1 mg/kg/day in patients ≤31 weeks adjusted (↑ risk of ototoxicity 👂☠)

    • Neonates: 0.5-1 mg/kg/dose q6-8h

    • Children: 0.5-1 mg/kg/dose q6-24h

      • Usual range 0.5-2 mg/kg/dose, rarely will use 3 mg/kg/dose for renal impairment (e.g., "diuretic challenge")

      • Max 6 mg/kg/dose (200 mg/dose, 10 mg/kg/day)

    • Adults: 20-80 mg/dose q6-12h

      • Titrate by 20 mg/dose q1-2h until desired effect seen

      • Max 200 mg/dose (≤600 mg/day)

    • Can also be given IM (1:1)

  • Continuous 🔁

    • Children: 0.05-0.4 mg/kg/h

      • May load with 0.1 mg/kg IV bolus

    • Adults: 10-40 mg/h

      • May load with 20-40 mg IV bolus

  • Note: onset within 5 mins, with peak in first 30 mins and duration of ~2 hours

• Note: bioavailability is variable; generally assume 2:1 potency for IV:enteral, but may want to be more cautious (1.5:1 or 1:1) depending on clinical scenario

Bumetanide (Bumex®) [UpToDate] [LPCH Lexicomp]

• Enteral 💊/🧪

  • Neonates: 0.01-0.05 mg/kg q12-48h

  • Infants/Children: 0.01-0.1 mg/kg q6-24h

    • Study of infants (0-6 mo) showed no improvement in diuretic effect above 0.04 mg/kg/dose

    • Max 10 mg/day

  • Adults: 0.5-1 mg q8-24h

    • Max 10 mg/day

  • Note: onset of diuresis 30-60 mins, with peak in 1-2 hours and duration of 4-6 hours

• Intravenous

  • Intermittent 💉/💪

    • Neonates: 0.01-0.05 mg/kg q12-48h

    • Infants/Children: 0.01-0.1 mg/kg/dose q6-24h

      • Study of infants (0-6 mo) showed no improvement in diuretic effect above 0.04 mg/kg/dose

      • Max 10 mg/day

    • Adults: 0.5-1 mg q8-24h

      • Max 10 mg/day

  • Continuous 🔁

    • Infants/Children: 5 mcg/kg/h

      • Titrate by 5 mcg/kg/h

      • Usual range 5-15 mcg/kg/h

      • Max 30 mcg/kg/h

    • Adults: 0.5-2 mg/h

      • May load with 1 mg IV bolus

      • Max 5 mg/h

  • Note: onset within minutes, with peak in first 30 mins

• Note: good bioavailability (>80%); assume 1:1 potency IV:PO

Ethacrynic acid (Edecrin®) [UpToDate] [Lexicomp]

• Warning: has significant drug-drug interactions; reserve for patients with sensitivity to sulfonamide-based loop diuretics (furosemide, bumetanide, torsemide) who are refractory to other diuretics.

• Enteral 💊/🧪

  • Children: 1 mg/kg q24h

    • Start with daily dosing; later may dose daily or divide BID/TID

    • Titrate q48-72h

    • Max 3 mg/kg/day (400 mg/day)

  • Adults: 25-50 mg q24h

    • Titrate q24h

    • Usual range 50-200 mg, daily or divided BID

    • Max 400 mg/day

• Intravenous

  • Intermittent 💉

    • Children: 0.5-1 mg/kg/dose q8-24h

      • Max 50 mg/dose

    • Adult: 50 mg or 0.5-1 mg/kg x1 dose

      • Max 100 mg x1 dose (if necessary may do 1 additional dose 8-12 hours later)

  • Continuous 🔁

    • Children:

      • 0.1 mg/kg/h

      • Usual range 0.1-0.35 mg/kg/h

      • Max 50 mg/kg/h

  • Note: risk of thrombophlebitis; avoid repeat IV dosing if possible, rotate IV access if additional doses are necessary

Chlorothiazide (Diuril®) [UpToDate] [LPCH Lexicomp]

• 5-10 mg/kg/dose Q6-12H. Ideally shouldn’t be less frequent than Q6H.

• Enteral 💊/🧪

  • Children:

    • 5-20 mg/kg q6-12h

    • Max 40 mg/kg/day

  • Adults:

    • 500-2000 mg/day, daily or divided BID

• Intravenous 💉

  • Children:

    • 2.5-10 mg/kg q6-12h

    • Typical 5-10 mg/kg q6-8h

    • Max 40 mg/kg/day

  • Adults:

    • 500 mg q6-24h

  • Note: avoid extravasation, extremely irritating to tissues

Hydrochlorothiazide (HCTZ) [UpToDate] [LPCH Lexicomp]

• Enteral 💊/🧪

  • Infants 2-6 months: 1-3 mg/kg/day, daily or divided BID

  • Infants ≥6 months/Children: 1-2 mg/kg/day, daily or divided BID

  • Max 37.5 mg/day for <2 years, 100 mg/day for 2-12 years, 200 mg/day for ≥12 years

Metolazone (Zaroxolyn®) [UpToDate] [LPCH Lexicomp]

• Metolazone 0.1-0.2 mg/kg/dose Q12H or 0.2-0.4 mg/kg/dose Q24H

Chlorthalidone (Hygroton®) [UpToDate] [LPCH Lexicomp]

• Enteral 💊

  • 0.3 mg/kg daily

  • Usual range ≤25 mg/day; >25 mg → ↑ risk of side effects without much improvement in diuretic effect

  • Max 2 mg/kg/day (50 mg/day)

• Intravenous 💉

  • 2.5-5 mg/kg/dose q6-12h

  • Max 40 mg/kg/day

Spironolactone (Aldactone®, CaroSpir®) [UpToDate] [LPCH Lexicomp]

• Enteral 💊/🧪*

  • Neonates: 1-3 mg/kg/day, q12-24h

  • Infants/Children: 1-3.3 mg/kg/day, q6-24h

    • Max 100 mg/day

  • Adults: 12.5-25 mg q24h

    • Max 100 mg/day

  • Note: liquid formulation (CaroSpir®) is not equivalent to tablet (15-37% higher serum concentration vs tablet)

• Sometimes packaged with HCTZ (Aldactazide®)

Amiloride (Midamor®) [UpToDate] [LPCH Lexicomp]

• Enteral 💊/🧪

  • 0.4 to 0.625 mg/kg (≤5 mg) q24h

  • Titrate by ≤5 mg/day

  • Max 20 mg/day