Should bumetanide be held in a patient receiving furosemide (Lasix) intravenously (IV) for treatment of volume overload?

From the Guidelines

Yes, you should hold bumetanide when a patient is already receiving intravenous furosemide for volume overload. Both medications are loop diuretics that work through the same mechanism of action by inhibiting the sodium-potassium-chloride cotransporter in the ascending loop of Henle, leading to increased urine output. Administering both medications simultaneously would be redundant and could potentially lead to excessive diuresis, causing dangerous electrolyte imbalances (particularly hypokalemia), dehydration, and acute kidney injury. If the current furosemide therapy is not providing adequate diuresis, consider either increasing the furosemide dose or switching completely to bumetanide (typically at a ratio of 40 mg furosemide to 1 mg bumetanide), rather than using both concurrently. Any change in diuretic therapy should be accompanied by close monitoring of fluid status, electrolytes (especially potassium), and kidney function to ensure safety and efficacy of the treatment 1.

Some key points to consider when managing volume overload with diuretics include:

• The initial dose of furosemide can be a bolus of 20-40 mg IV, with the option to increase the dose according to renal function and history of chronic oral diuretic use 1.
• The total furosemide dose should remain < 100 mg in the first 6 hours and 240 mg during the first 24 hours 1.
• In patients already taking diuretic, 2.5 times the existing oral dose is recommended, with the option to repeat as needed 1.
• Close monitoring of the patient's clinical status, including urine output, electrolytes, and kidney function, is crucial to ensure the safety and efficacy of diuretic therapy 1.

Overall, the goal of diuretic therapy in volume overload is to eliminate clinical evidence of fluid retention while minimizing the risk of adverse effects, and this can often be achieved with careful dose titration and monitoring of a single loop diuretic, such as furosemide 1.

From the FDA Drug Label

Almost equal diuretic response occurs after oral and parenteral administration of bumetanide. Therefore, if impaired gastrointestinal absorption is suspected or oral administration is not practical, bumetanide should be given by the intramuscular or intravenous route. Successful treatment with bumetanide following instances of allergic reactions to furosemide suggests a lack of cross-sensitivity. The patient is receiving furosemide IV, and there is no direct information that suggests an interaction between bumetanide and furosemide that would necessitate holding bumetanide.

• Key point: The lack of cross-sensitivity between bumetanide and furosemide is noted.
• Clinical decision: There is no direct information to support holding bumetanide in a patient receiving furosemide IV for treatment of volume overload, but caution should be exercised due to the potential for increased diuretic effect when using two loop diuretics concurrently 2.

From the Research

Loop Diuretics and Volume Overload Treatment

• The treatment of volume overload often involves the use of loop diuretics, such as furosemide and bumetanide 3, 4, 5, 6, 7.
• Furosemide is commonly used to prevent transfusion-associated circulatory overload (TACO) and to manage fluid overload in patients with acute kidney injury (AKI) 3, 4.
• Bumetanide is more potent than furosemide and has a longer half-life in neonates, but its use in adults is less well-studied 5, 6.

Interaction between Furosemide and Bumetanide

• There is limited evidence on the interaction between furosemide and bumetanide, but it is suggested that bumetanide may be more effective in certain patient populations, such as those with heart failure or nephrotic syndrome 7.
• The pharmacokinetic profiles of torsemide and bumetanide are more favorable than furosemide, but more studies are needed to confirm their efficacy and safety in different patient populations 7.

Holding Bumetanide in Patients Receiving Furosemide IV

• There is no direct evidence to suggest that bumetanide should be held in patients receiving furosemide IV for treatment of volume overload.
• However, the use of multiple loop diuretics may increase the risk of adverse effects, such as electrolyte imbalances and ototoxicity 5, 6.
• The decision to hold bumetanide in patients receiving furosemide IV should be made on a case-by-case basis, taking into account the patient's individual needs and medical history.