What is the recommended dose of furosemide (Lasix) for patients with cirrhosis and ascites?

Recommended Dosage of Furosemide for Cirrhosis with Ascites

The recommended initial dose of furosemide for patients with cirrhosis and ascites is 40 mg/day orally, typically given in combination with spironolactone 100 mg/day, with doses that can be increased simultaneously every 3-5 days (maintaining a 100:40 mg ratio) up to a maximum of 160 mg/day of furosemide and 400 mg/day of spironolactone. 1

Initial Dosing Strategy

• The standard diuretic regimen for cirrhotic ascites consists of single morning doses of oral spironolactone and furosemide, beginning with 100 mg of spironolactone and 40 mg of furosemide 1
• Oral administration is preferred over intravenous furosemide due to good oral bioavailability in cirrhotic patients and the risk of acute reductions in glomerular filtration rate with IV administration 1
• Single morning dosing is recommended to maximize patient compliance 1

Dose Titration

• Both diuretics can be increased simultaneously every 3-5 days (maintaining the 100 mg:40 mg ratio) if weight loss and natriuresis are inadequate 1
• This ratio generally maintains normokalemia while achieving effective diuresis 1
• Maximum recommended doses are 400 mg/day of spironolactone and 160 mg/day of furosemide 1
• For patients without edema, weight loss should be limited to 0.5 kg/day; for those with edema, there is no strict limit but careful monitoring is required 1

Special Considerations

• Furosemide can be temporarily withheld in patients presenting with hypokalemia, which is common in alcoholic hepatitis 1
• Patients with parenchymal renal disease may tolerate less spironolactone due to risk of hyperkalemia 1
• In cases of tender gynecomastia, amiloride (10-40 mg/day) can be substituted for spironolactone 1
• Diuretics should be discontinued if severe hyponatremia (serum sodium <120-125 mmol/L), acute kidney injury, worsening hepatic encephalopathy, or incapacitating muscle cramps develop 1

Alternative Approaches

• For the first episode of ascites, some evidence suggests starting with spironolactone monotherapy and adding furosemide only if needed, particularly in outpatient settings 1
• However, most patients eventually require combination therapy, and starting with both drugs appears to be the preferred approach for achieving rapid natriuresis while maintaining normal potassium levels 1
• For patients with tense ascites, large-volume paracentesis followed by diuretic therapy is appropriate 1

Monitoring

• Regular monitoring of body weight, vital signs, serum creatinine, sodium, and potassium is essential during diuretic therapy 1
• If serum sodium decreases below 125 mmol/L, diuretics should be reduced or discontinued 1
• Loop diuretics should be reduced or stopped in case of hypokalemia (<3 mmol/L), while aldosterone antagonists should be reduced or stopped in case of hyperkalemia (>6 mmol/L) 1

Refractory Ascites

• Refractory ascites is defined as fluid overload that fails to respond to sodium restriction and maximum diuretic doses (spironolactone 400 mg/day and furosemide 160 mg/day) 1, 2
• For these patients, large-volume paracentesis, transjugular intrahepatic portosystemic shunt (TIPS), or liver transplantation may be considered 2