Can furosemide (Lasix) cause vestibulotoxicity?

Furosemide and Vestibulotoxicity

Yes, furosemide (Lasix) can cause vestibulotoxicity, particularly when administered at high doses, given intravenously, or used concomitantly with other ototoxic medications such as aminoglycosides. 1, 2

Mechanism and Risk Factors

• Furosemide can cause ototoxicity affecting both the vestibular and auditory systems, resulting in balance disturbances and hearing impairment 2
• The risk of vestibulotoxicity is significantly increased with:
  • Rapid intravenous administration (bolus injection) 1, 3
  • High doses of furosemide 1, 3
  • Severe renal impairment 1
  • Hypoproteinemia (low serum albumin) 1, 4
  • Concomitant use of other ototoxic medications, particularly aminoglycoside antibiotics 1, 5
  • Advanced age 2, 1

Clinical Manifestations

• Vestibular symptoms may include vertigo, dizziness, and balance disturbances 6, 2
• Auditory symptoms often accompany vestibular toxicity and include tinnitus and hearing loss that can be reversible or irreversible 1, 6
• Symptoms may appear suddenly, particularly with intravenous administration 1, 3
• In some cases, the ototoxicity may be permanent, though it is often transient 3, 6

Synergistic Effects with Other Medications

• The combination of furosemide with aminoglycoside antibiotics significantly increases the risk of vestibulotoxicity 1, 5
• The FDA label specifically warns against using furosemide concomitantly with ethacrynic acid due to increased risk of ototoxicity 1
• Cisplatin and furosemide given together also increase the risk of ototoxic effects 1, 7
• CYP3A4 inhibitors (like diltiazem) can increase furosemide levels and potentially enhance ototoxicity 7, 1

Prevention and Monitoring

• To minimize the risk of vestibulotoxicity:
  • Avoid rapid intravenous administration; controlled IV infusion not exceeding 4 mg/minute is recommended 1, 3
  • Use the lowest effective dose 3, 1
  • Consider alternative diuretics in patients at high risk 3, 2
  • Monitor vestibular function in patients receiving high-dose or prolonged therapy 2, 6
  • Avoid combining with other ototoxic medications when possible 1, 5
  • Consider baseline and follow-up vestibular testing for high-risk patients 2, 6

Clinical Approach for Patients on Furosemide

• For patients requiring furosemide therapy:
  • Assess for risk factors of vestibulotoxicity before initiating therapy 1, 6
  • Consider baseline vestibular testing in high-risk patients 2, 6
  • Monitor for early symptoms of vestibular dysfunction (dizziness, vertigo, imbalance) 2, 6
  • If vestibular symptoms develop, consider dose reduction or alternative diuretic therapy 3, 1
  • In cases where furosemide must be continued despite early ototoxic symptoms, close monitoring is essential 1

Special Considerations

• In patients with tuberculosis receiving streptomycin (which is also vestibulotoxic), the concomitant use of furosemide significantly increases the risk of vestibular damage 2
• Patients with hypoalbuminemia are at particularly high risk for furosemide ototoxicity due to increased free (unbound) drug concentration 4, 1
• The elderly are more susceptible to furosemide-induced vestibulotoxicity and require careful monitoring 2, 1