Can Lasix (furosemide) contribute to hearing loss?

Furosemide and Hearing Loss: Risk Assessment and Management

Yes, Lasix (furosemide) can contribute to hearing loss, particularly when administered rapidly intravenously, at high doses, or in combination with other ototoxic medications.

Mechanism and Risk Factors

Furosemide can cause ototoxicity through several mechanisms:

• Direct toxic effects on the inner ear structures
• Interference with strial adenylate cyclase and Na+/K+-ATPase
• Inhibition of the Na-K-2Cl cotransporter in the stria vascularis
• Reduction of blood flow to the lateral wall of the cochlea 1

Key Risk Factors for Furosemide-Induced Hearing Loss:

• Administration factors:

  • Rapid intravenous injection (highest risk)
  • High doses
  • Prolonged therapy

• Patient factors:

  • Severe renal impairment
  • Hypoproteinemia
  • Dehydration
  • Advanced age
  • Pre-existing hearing problems

• Concomitant medications:

  • Aminoglycoside antibiotics (significant synergistic effect)
  • Ethacrynic acid (another loop diuretic)
  • Cisplatin and other ototoxic drugs
  • PDE-5 inhibitors like sildenafil 2, 3

Clinical Presentation and Course

Furosemide-induced hearing loss typically presents as:

• Tinnitus (early warning sign)
• Sensorineural hearing loss
• Can affect high frequencies first
• May be bilateral

The hearing loss is often temporary but can become permanent, especially with:

• Continued exposure despite symptoms
• Combination with other ototoxic drugs
• Underlying renal dysfunction 2, 4

Prevention and Monitoring

To minimize risk of furosemide-induced hearing loss:

1. Dosing considerations:

   • Avoid rapid IV administration (infusion rate not exceeding 4 mg/minute for adults) 2
   • Use lowest effective dose
   • Consider dose reduction in elderly patients or those with renal impairment

2. Monitoring:

   • Baseline audiometry before starting therapy in high-risk patients
   • Regular audiometric testing during prolonged therapy
   • Monitor for early symptoms of ototoxicity (tinnitus, hearing changes)

3. Drug interactions:

   • Avoid concurrent use with aminoglycosides except in life-threatening situations
   • Do not use concomitantly with ethacrynic acid
   • Use caution with other potentially ototoxic drugs 2

Management of Suspected Ototoxicity

If ototoxicity is suspected:

1. Immediate action:

   • Stop furosemide administration if tinnitus or hearing changes occur
   • Switch to alternative medications if possible

2. Assessment:

   • Perform audiometric evaluation
   • Rule out other causes of hearing loss

3. Follow-up:

   • Monitor for recovery (may take weeks to months)
   • Consider permanent hearing aids if hearing loss persists 5

Special Considerations

Aminoglycoside Combination

The combination of furosemide with aminoglycosides significantly increases ototoxicity risk. The aminoglycoside increases cell membrane permeability in the inner ear, allowing furosemide to penetrate in higher concentrations 6.

Renal Dysfunction

Patients with renal impairment are at particularly high risk due to decreased drug clearance and potential accumulation 2.

Pediatric Patients

Neonates and children are especially vulnerable to ototoxicity. Literature reports indicate that premature infants with post-conceptual age less than 31 weeks receiving doses exceeding 1 mg/kg/24 hours may develop toxic levels associated with ototoxicity 2.

Conclusion

While furosemide is an essential medication for many conditions, its potential to cause hearing loss should be carefully considered, especially in high-risk patients. Proper dosing, administration techniques, monitoring, and awareness of drug interactions can significantly reduce the risk of this adverse effect.