Schedule H

Oral, Intravenous, Intramuscular

• Tablets: 20 mg, 40 mg

• Oral solution: 10 mg/mL (limited to select hospital settings)

• Injection: 10 mg/mL (2 mL ampoule = 20 mg; 4 mL ampoule = 40 mg)

INDICATIONS + DOSING — FOR CLINICIAN USE ONLY

Primary Indications (Approved / Standard in India)

1. Congestive Heart Failure (CHF) — Volume Overload / Pulmonary Congestion

Parameter Oral Intravenous

Starting dose 20–40 mg once daily 20–40 mg slow IV push (over 1–2 min)

Titration Increase by 20–40 mg every 6–8 hours based on response Repeat dose in 2 hours if inadequate response

Usual maintenance 40–80 mg/day (single or divided doses) Convert to oral once stable

Maximum dose 600 mg/day (divided doses) 200 mg/bolus; higher only under specialist care

Clinical Notes:

• Monitor daily weight, fluid balance, serum electrolytes, BP

• Consider potassium supplementation or combine with spironolactone if hypokalaemia develops

1. Acute Pulmonary Oedema

Step Action

Starting dose IV 40 mg bolus (slow push over 1–2 min)

Titration May repeat 40–80 mg IV in 1–2 hours if response inadequate

If already on oral loop diuretic Give IV dose equivalent to patient's total daily oral dose

Maximum dose 200 mg per bolus; higher doses require ECG and electrolyte monitoring

Clinical Notes:

• Administer with oxygen and positioning

• Rapid infusion increases ototoxicity risk

1. Chronic Kidney Disease with Volume Overload

Parameter Recommendation

Starting dose 40–80 mg oral once or twice daily

Titration Increase to 80–160 mg twice daily based on clinical response

Usual maintenance 80–320 mg/day in divided doses

Maximum dose 600 mg/day oral (divided)

Clinical Notes:

• Higher doses often required due to reduced tubular secretion in low GFR

• Consider adding thiazide-type diuretic for sequential nephron blockade in resistant oedema

1. Hypertension (Volume-dependent or Resistant)

Parameter Recommendation

Starting dose 20 mg once or twice daily

Titration Increase to 40 mg twice daily if needed

Usual maintenance 20–80 mg/day

Maximum dose 80 mg/day (as adjunct therapy)

Clinical Notes:

• Not first-line antihypertensive

• Reserve for patients with concurrent fluid overload or CKD

Secondary Indications — Adults Only (Off-label)

Indication Dose Duration Notes

Acute Hypercalcaemia— OFF-LABEL 20–40 mg IV every 2–4 hours Until calcium normalises Administer with IV saline; specialist supervision essential; monitor calcium and fluid balance. Based on Indian nephrology practice.

Ascites in Cirrhosis (spironolactone-resistant) — OFF-LABEL 20–40 mg oral daily; titrate as needed Long-term maintenance Combine with spironolactone (40:100 mg ratio preferred). Monitor for encephalopathy and electrolyte disturbance. Based on Indian hepatology protocols.

PAEDIATRIC DOSING (Specialist Only)

Primary Indications

1. Oedema (Cardiac / Renal / Hepatic Causes)

Neonates (term) IV or Oral 0.5–1 mg/kg Every 12–24 hours 2 mg/kg

Infants (1 month – 1 year) IV or Oral 1–2 mg/kg Every 6–12 hours 4 mg/kg

Children (1–12 years) IV or Oral 1–2 mg/kg Every 6–8 hours 6 mg/kg (max 40 mg/dose)

Adolescents (>12 years) IV or Oral 20–40 mg Once or twice daily 80 mg/dose

Safety Monitoring:

• Serum electrolytes (K⁺, Na⁺, Ca²⁺, Mg²⁺)

• Fluid balance, daily weight

• Audiometry if repeated high-dose IV use

Cautions:

• Avoid in premature neonates unless essential — increased ototoxicity and nephrocalcinosis risk

1. Acute Kidney Injury (Oliguric Phase) — Nephrologist Only

Parameter Recommendation

Starting dose 1–2 mg/kg IV

Titration May increase to 4 mg/kg if no response

Maximum dose 6 mg/kg/dose (specialist discretion)

Clinical Notes:

• Response-based dosing; not for routine use

• Close monitoring of urine output and electrolytes mandatory

Secondary Indications — Paediatric (Off-label)

Indication Dose Duration Notes

Bronchopulmonary Dysplasia (BPD) — OFF-LABEL 1 mg/kg/dose oral or IV, once or twice daily Short-term (days to weeks) Specialist (neonatologist) only. Limited to NICU settings. Risk of electrolyte imbalance. Based on tertiary NICU protocols in India.

Age Restriction: Not recommended below 4 weeks of age except under specialist supervision.

Mild–Moderate impairment (eGFR 15–60) No dose reduction; may need higher doses due to reduced efficacy

Severe impairment (eGFR <15) Higher doses often required; monitor volume and electrolytes closely

Dialysis patients Can be used for residual diuresis; not removed by haemodialysis

Note: Avoid dehydration. Combine with thiazide for synergy in resistant cases.

• Anuria unresponsive to fluid challenge

• Severe hypovolaemia or dehydration

• Known hypersensitivity to furosemide or sulfonamides

• Severe uncorrected hypokalaemia or hyponatraemia

• Hepatic coma or pre-coma (unless under specialist supervision)

• Gout or hyperuricaemia (may precipitate acute attack)

• Diabetes mellitus (may worsen glycaemic control)

• Prostatic hypertrophy / bladder outlet obstruction

• Pre-existing hearing impairment

• Concurrent nephrotoxic or ototoxic drug use

• Elderly patients (increased risk of falls, hypotension)

• Severe electrolyte disturbances

Parameter Information

Risk category Use only if benefit clearly outweighs risk

Concerns May reduce placental perfusion; risk of oligohydramnios, fetal electrolyte imbalance

Preferred alternatives Methyldopa, labetalol for hypertension in pregnancy

When to use Only if volume overload poses immediate maternal risk

Monitoring Fetal growth (serial USG), maternal electrolytes, BP

Parameter Information

Compatibility Generally compatible with breastfeeding

Milk levels Low; minimal infant exposure expected

Concerns High doses may reduce milk production

Monitoring in infant Weight gain, feeding adequacy, hydration status

Preferred alternatives None specifically preferred; continue if clinically indicated

Parameter Recommendation

Starting dose 20 mg once daily (lower end of range)

Titration Slow; increase cautiously based on response

Special risks Orthostatic hypotension, falls, hyponatraemia, dehydration, acute kidney injury

Monitoring BP (including postural), renal function, electrolytes at baseline and periodically

Drug Interaction Management

Aminoglycosides(gentamicin, amikacin) Additive ototoxicity and nephrotoxicity, especially with IV furosemide Avoid combination if possible; if essential, monitor hearing and renal function

Digoxin Hypokalaemia increases digoxin toxicity risk Monitor potassium; supplement or add K⁺-sparing diuretic

Lithium Reduced lithium clearance; increased toxicity risk Monitor lithium levels closely; dose adjustment may be needed

NSAIDs Reduce diuretic efficacy; increase AKI risk Avoid routine use; use paracetamol as alternative analgesic

Drug Interaction Management

Corticosteroids Additive hypokalaemia Monitor potassium; consider supplementation

Antidiabetic agents May blunt hypoglycaemic effect Monitor blood glucose; adjust antidiabetic dose if needed

ACE inhibitors / ARBs Additive hypotension, especially first dose Start at low dose; monitor BP

Proton pump inhibitors Combined risk of hypomagnesaemia Monitor magnesium in long-term use

Antipsychotics(haloperidol, risperidone) Electrolyte imbalance may prolong QTc Monitor ECG and electrolytes

Antiepileptics(phenytoin) May reduce furosemide absorption Monitor diuretic response

• Hypokalaemia

• Hyponatraemia

• Postural hypotension

• Hyperuricaemia

• Dizziness, fatigue

• Dehydration

• Hyperglycaemia

• Increased urinary frequency

Effect Notes

Ototoxicity Risk increased with rapid IV infusion, high doses, renal impairment, or concurrent aminoglycosides; may be irreversible

Severe electrolyte disturbance Hypokalaemia, hyponatraemia, hypomagnesaemia — can cause arrhythmias

Stevens-Johnson Syndrome / TEN Rare; discontinue immediately if rash develops

Acute pancreatitis Rare; consider if unexplained abdominal pain occurs

Photosensitivity Advise sun protection

Blood dyscrasias Agranulocytosis, thrombocytopenia (rare)

Long-term Electrolytes, renal function, uric acid every 1–3 months

CHF / oedema management Daily weight, fluid balance assessment

High-dose IV or concurrent digoxin ECG monitoring

Paediatric (repeated IV doses) Audiometry

• Lasix (Sanofi)

• Frusemide (generic — multiple manufacturers)

• Frusenex (Macleods)

• Frusol (Micro Labs)

• Furoped (Ipca)

• Dytor (combination with torsemide — note: different loop diuretic; FDC with spironolactone also available)

Note: Listed under NLEM 2022; prices regulated by NPPA. Government supply rates may be lower.

1. IV administration: Always give slow IV push (over 1–2 minutes); rapid injection increases ototoxicity risk.

1. Potassium management: Routinely monitor potassium; consider adding spironolactone or potassium chloride supplementation if persistent hypokalaemia.

1. Diuretic resistance: In resistant oedema, combine with thiazide (metolazone or hydrochlorothiazide) for sequential nephron blockade — requires close monitoring.

1. Avoid NSAIDs: These blunt the diuretic effect and increase AKI risk; use paracetamol for analgesia.

1. Metabolic effects: May worsen diabetes control and precipitate gout — monitor glucose and uric acid accordingly.

1. IV to oral conversion: Oral bioavailability is approximately 50%; when converting from IV to oral, consider doubling the dose or using more frequent dosing.

furosemide; loop diuretic; CHF; pulmonary oedema; CKD; oedema; hypokalaemia; NLEM India; NPPA; electrolyte monitoring; IV diuresis

RxIndia v1.1 — 05 Jan 2025

• CDSCO approved prescribing information

• Indian Pharmacopoeia / National Formulary of India

• NLEM 2022

• API Textbook of Medicine

• AIIMS Drug Formulary

• Indian Society of Nephrology Guidelines

• Indian Academy of Pediatrics (IAP) treatment protocols

• Harrison's Principles of Internal Medicine

• Goodman & Gilman's The Pharmacological Basis of Therapeutics

• Tertiary NICU protocols (for paediatric off-label use)