How long after administering albumin should Lasix (furosemide) be given?

From the Guidelines

Furosemide (Lasix) should be administered approximately 15-30 minutes after albumin infusion for optimal diuretic effect. This timing allows the albumin to first expand the intravascular volume and mobilize fluid from edematous tissues into the circulation. When furosemide is then administered, there is more fluid available within the vascular space for the diuretic to act upon, enhancing its effectiveness. The albumin-furosemide combination works synergistically because albumin binds to furosemide in the bloodstream, delivering more of the diuretic to the kidneys and prolonging its action. Additionally, albumin helps maintain oncotic pressure within the vasculature, preventing immediate redistribution of fluid back into tissues. For patients with conditions like cirrhosis, nephrotic syndrome, or severe hypoalbuminemia, this sequential administration is particularly important as these patients often have poor response to furosemide alone due to decreased effective circulating volume. The standard adult dose of furosemide following albumin typically ranges from 20-80 mg intravenously, but should be adjusted based on the patient's renal function, prior diuretic exposure, and clinical condition, as recommended by guidelines such as those from the European Association for the Study of the Liver 1.

Some key points to consider when administering furosemide after albumin include:

• Monitoring the patient's volume status and renal function closely, as furosemide can exacerbate dehydration and electrolyte imbalances 1
• Adjusting the dose of furosemide based on the patient's response to treatment, with the goal of achieving a maximum weight loss of 0.5 kg/day in patients without edema and 1 kg/day in patients with edema 1
• Being aware of the potential for furosemide to cause hypokalemia, particularly in patients with cirrhosis or other conditions that affect potassium levels 1
• Considering alternative diuretics, such as torasemide, in patients who do not respond to furosemide 1

It's also important to note that the use of albumin and furosemide in combination is supported by guidelines such as those from the European Association for the Study of the Liver 1, which recommend the use of albumin to prevent circulatory dysfunction after large-volume paracentesis and the use of diuretics to prevent the re-accumulation of ascites.

From the Research

Administration Timing of Lasix after Albumin

• The optimal timing for administering Lasix (furosemide) after albumin is not explicitly stated in the provided studies, but we can infer some guidelines based on the effects of combining these two substances.
• A study from 2006 2 compared the diuretic effect of furosemide mixed with human albumin or fresh frozen plasma in ICU patients with hypoalbuminemia. The study administered furosemide mixed with albumin or fresh frozen plasma intravenously for 60 minutes. However, it does not specify the exact timing after albumin administration.
• Another study from 2014 3 proposed a pilot randomized controlled trial to investigate the hypothesis that intravenous 25% albumin plus furosemide improves diuresis, oxygenation, and hemodynamic stability in critically ill, hypoalbuminemic patients. The study planned to administer diuretics within 2 hours following the study treatment (albumin or placebo).
• A 2012 study 4 found that adding albumin to a furosemide infusion did not enhance diuresis obtained with furosemide alone in critically ill patients. This study does not provide specific guidance on the timing of Lasix administration after albumin.
• A randomized controlled study from 2012 5 compared the efficacy of diuretics between furosemide alone and the combination of furosemide plus albumin in stable hypoalbuminemic CKD patients. The study found that the combination of furosemide and albumin had a superior short-term efficacy over furosemide alone in enhancing water and sodium diuresis.
• A study from 2001 6 evaluated the effect of albumin and furosemide therapy on plasma volume in nephrotic children. The study administered albumin and furosemide therapy and found a transient increase in plasma volume 1 hour after therapy, with a decrease in edema and body weight 24 hours later.

Key Findings

• The combination of furosemide and albumin may have a superior short-term efficacy in enhancing diuresis compared to furosemide alone in certain patient populations, such as those with hypoalbuminemic chronic kidney disease 5.
• Administering diuretics within 2 hours following albumin treatment may be a reasonable approach, as proposed in the 2014 study 3.
• However, the optimal timing for administering Lasix after albumin may depend on various factors, including the patient's condition, the dose and type of albumin used, and the specific clinical context.