Should Furosemide (Lasix) 40mg be continued in a patient with impaired liver function?

From the Guidelines

Furosemide 40mg should be continued with caution in patients with impaired liver function, with close monitoring of renal function, electrolytes, and clinical response, as recommended by the most recent guidelines 1. When considering the management of patients with impaired liver function, such as those with cirrhosis, it's crucial to balance the benefits of diuretic therapy, like furosemide, against potential risks. The guidelines from 2021 1 suggest that for patients with cirrhosis and moderate ascites, spironolactone should be commenced first, and if there's a suboptimal response, furosemide can be added, starting at 40mg and increasing up to 160mg/day. Key considerations include:

• Monitoring for diuretic adverse events and temporarily discontinuing diuretics if electrolyte imbalance, worsening hypokalaemia, hyperkalaemia, serum creatinine elevation, hepatic encephalopathy, or muscle cramps occur.
• Adjusting the dose based on the patient's response and laboratory values, aiming for a diuretic response defined as 1kg weight loss/day if edema is present and 0.5kg weight loss/day if no edema is present.
• Being aware that furosemide can precipitate hepatic encephalopathy in susceptible patients by causing electrolyte disturbances or excessive diuresis, as also cautioned in earlier guidelines 1. Given the potential for severe complications, careful monitoring and a cautious approach to adjusting furosemide doses are essential, prioritizing the patient's morbidity, mortality, and quality of life outcomes.

From the FDA Drug Label

In patients with hepatic cirrhosis and ascites, Furosemide tablets therapy is best initiated in the hospital. In hepatic coma and in states of electrolyte depletion, therapy should not be instituted until the basic condition is improved Sudden alterations of fluid and electrolyte balance in patients with cirrhosis may precipitate hepatic coma; therefore, strict observation is necessary during the period of diuresis.

The patient with impaired liver function should be under strict observation. Furosemide 40mg tablet can be continued, but therapy should be initiated in the hospital for patients with hepatic cirrhosis and ascites. However, if the patient has hepatic coma or electrolyte depletion, Furosemide therapy should not be instituted until the basic condition is improved 2.

From the Research

Furosemide 40mg Tablet Continuation in Impaired Liver Function

• The decision to continue Furosemide 40mg in a patient with impaired liver function should be based on careful consideration of the patient's individual circumstances and the potential risks and benefits of the medication 3, 4, 5, 6.
• Studies have shown that Furosemide can be effective in treating ascites in patients with liver cirrhosis, but it can also cause adverse reactions such as electrolyte disturbances and volume depletion 4, 5.
• The combination of spironolactone and Furosemide has been shown to be effective in treating ascites and improving acid-base disorders in patients with liver cirrhosis 3, 6.
• However, the use of Furosemide in patients with impaired liver function requires careful monitoring of the patient's condition and adjustment of the dosage as needed to minimize the risk of adverse reactions 4, 5.
• Clinical reasoning and individualized decision-making are essential in determining the best course of treatment for each patient, taking into account their unique circumstances and the potential risks and benefits of the medication 7.

Key Considerations

• The patient's liver function and the presence of any underlying conditions that may affect the metabolism and excretion of Furosemide 4, 5.
• The potential risks and benefits of continuing Furosemide 40mg, including the risk of adverse reactions and the potential benefits of treating ascites and improving acid-base disorders 3, 6.
• The need for careful monitoring of the patient's condition and adjustment of the dosage as needed to minimize the risk of adverse reactions 4, 5.
• The importance of clinical reasoning and individualized decision-making in determining the best course of treatment for each patient 7.