What is the maximum dose of bumetanide (Bumetanide) for Congestive Heart Failure (CHF)?

Maximum Dose of Bumetanide for Congestive Heart Failure

The maximum recommended daily dose of bumetanide for congestive heart failure is 5-10 mg. 1

Dosing Guidelines

Bumetanide is a potent loop diuretic used in the management of fluid overload in congestive heart failure. According to the European Society of Cardiology guidelines, the dosing parameters are:

• Initial dose: 0.5-1.0 mg orally or intravenously
• Maximum recommended daily dose: 5-10 mg 1

Pharmacological Considerations

Bumetanide is approximately 40 times more potent than furosemide, with the exception of its effects on potassium excretion where its potency is comparatively lower 2. This high potency means that careful dose titration is essential to avoid excessive diuresis and electrolyte imbalances.

Dosing Algorithm

1. Initial therapy: Start with 0.5-1.0 mg once daily
2. Titration: Increase dose based on clinical response (diuresis, weight loss, symptom improvement)
3. Maintenance: Adjust to lowest effective dose that maintains euvolemia
4. Refractory cases: May require up to maximum dose (5-10 mg daily)
5. Severe cases: In patients with diuretic resistance, doses up to 15 mg/day have been used, particularly in those with chronic renal failure or nephrotic syndrome 2

Monitoring Requirements

When using bumetanide, especially at higher doses, careful monitoring is essential:

• Serum creatinine and electrolytes should be checked 5-7 days after initiation or dose adjustment
• Continue monitoring every 5-7 days until values stabilize
• Once stable, check every 3-6 months 1

Special Considerations

• Renal impairment: Patients with reduced kidney function may require higher doses due to decreased renal clearance of the drug 1
• Combination therapy: For diuretic resistance, consider adding thiazide diuretics or spironolactone rather than exceeding maximum bumetanide dose 3
• Timing of administration: Evening administration may be preferred by many patients and has been associated with increased 24-hour sodium excretion 4

Common Side Effects

At higher doses, be vigilant for:

• Hypokalaemia
• Hypomagnesaemia
• Hyponatraemia
• Hyperuricaemia
• Glucose intolerance
• Acid-base disturbances 1

Clinical Pearls

• Bumetanide has a rapid onset of action (within 30 minutes) and duration of 3-6 hours 2
• Bioavailability is approximately 81% with relatively low variability, making transition from IV to oral dosing predictable 5
• Unlike some other diuretics, bumetanide has not been associated with significant hyperuricemic effects 4
• In patients with severe heart failure, combining bumetanide with ACE inhibitors and spironolactone may be more effective than high-dose bumetanide alone 3