What are the side effects of bumetanide?

Bumetanide Side Effects

Bumetanide commonly causes electrolyte disturbances (particularly hypokalemia, hyponatremia, hypochloremia, and hypomagnesemia), dehydration, and azotemia, which can lead to significant morbidity and mortality if not properly monitored. 1

Common Side Effects

Electrolyte Abnormalities

• Hypokalemia: Occurs in approximately 14.7% of patients 1
• Hypochloremia: Seen in 14.9% of patients 1
• Hyponatremia: Affects 9.2% of patients 1
• Hyperuricemia: Observed in 18.4% of patients 1

Renal Effects

• Azotemia: Occurs in 10.6% of patients 1
• Increased serum creatinine: Seen in 7.4% of patients 1
• Renal failure: Rare but serious complication (0.1%) 1
• Dose-dependent renal decline: Higher doses cause more rapid decline in eGFR 2

Neurological Effects

• Dizziness: Reported in 1.1% of patients 1
• Headache: Occurs in 0.6% of patients 1
• Encephalopathy: Particularly in patients with pre-existing liver disease (0.6%) 1
• Vertigo: Reported in approximately 0.1% of patients 1

Musculoskeletal Effects

• Muscle cramps: Most frequent clinical adverse reaction (1.1%) 1
• Myalgias and muscle tenderness: Especially in patients with renal failure receiving high doses 3
• Weakness: Reported in 0.2% of patients 1
• Arthritic pain: Occurs in 0.2% of patients 1

Cardiovascular Effects

• Hypotension: Seen in 0.8% of patients 1
• Electrocardiogram changes: Reported in 0.4% of patients 1
• Chest pain: Rare (0.1%) 1

Gastrointestinal Effects

• Nausea: Occurs in 0.6% of patients 1
• Vomiting: Reported in 0.2% of patients 1
• Abdominal pain: Seen in 0.2% of patients 1
• Dry mouth: Rare (0.1%) 1

Dermatological Effects

• Pruritus: Reported in 0.4% of patients 1
• Hives: Seen in 0.2% of patients 1
• Rash: Occurs in 0.2% of patients 1

Hematological Effects

• Thrombocytopenia: Rare but reported in postmarketing experience 1
• Deviations in hemoglobin, hematocrit, WBC, and differential counts: Uncommon 1

Other Effects

• Impaired hearing: Reported in 0.5% of patients 1
• Hyperglycemia: Occurs in 6.6% of patients 1
• Fatigue: Rare (0.1%) 1
• Dehydration: Rare (0.1%) 1

Special Considerations

Renal Impairment

• Patients with chronic kidney disease are at higher risk for adverse effects and may require dose adjustments 2
• Bumetanide may be less effective in patients with severe renal impairment (GFR <5 ml/min) and can cause more muscle pain and stiffness in these patients 4

Hepatic Disease

• Patients with liver disease are at increased risk for encephalopathy 1
• Careful monitoring is required when using bumetanide in patients with ascites due to cirrhosis 2

Heart Failure

• Loop diuretics including bumetanide are associated with more severe renal decline and higher risk of hospital admission and mortality in heart failure patients 2
• The renal decline is dose-dependent with higher doses causing more rapid decline in eGFR 2

Monitoring Recommendations

1. Serum Electrolytes:

   • Check serum potassium, sodium, chloride, and magnesium periodically 1
   • Monitor within 24-48 hours of initiating therapy 5

2. Renal Function:

   • Monitor serum creatinine and BUN, especially with high doses or prolonged treatment 1
   • Check renal function after 1-2 days of starting treatment 5
   • Consider suspending treatment if creatinine increases >100% or >3 mg/dl 5

3. Blood Glucose:

   • Periodic determinations of blood sugar, particularly in patients with diabetes 1

4. Clinical Monitoring:

   • Regular assessment of symptoms and signs of congestion 5
   • Daily weight measurements to assess fluid status 5
   • Monitor urine output 5

Risk Mitigation Strategies

1. Dose Optimization:

   • Use the lowest effective dose to maintain euvolemia 5
   • Start with lower doses in patients with renal impairment 2

2. Electrolyte Management:

   • Consider potassium supplements or potassium-sparing diuretics if necessary 1
   • Monitor serum potassium closely, especially when used with other medications that affect potassium levels 1

3. Drug Interactions:

   • Avoid concurrent use with nephrotoxic drugs 1
   • Use caution when combining with aminoglycoside antibiotics due to increased risk of ototoxicity 1
   • Avoid concurrent use with indomethacin as it may reduce bumetanide effectiveness 1
   • Monitor closely when used with antihypertensives as bumetanide may potentiate their effects 1

4. Special Populations:

   • Use with caution in pregnancy (Category C) 1
   • Adjust dosing in elderly patients (>59 years) 2

Bumetanide is approximately 40 times more potent than furosemide on a milligram-for-milligram basis 6, 7, but may have a lower incidence of ototoxicity compared to furosemide 7. This makes it a potential alternative for patients at increased risk of hearing impairment.