What are the contraindications for Furosemide (Lasix) injections?

Contraindications for Injectable Furosemide

Furosemide injection is absolutely contraindicated in patients with anuria and in those with a history of hypersensitivity to furosemide. 1

Absolute Contraindications

FDA-Labeled Contraindications

• Anuria: Furosemide must not be administered to patients with complete absence of urine output 1
• Hypersensitivity: Any prior allergic reaction to furosemide is an absolute contraindication 1

Critical Clinical Contraindications from Guidelines

Severe Hyponatremia

• Serum sodium <120-125 mmol/L requires immediate discontinuation of furosemide 2, 3
• Even sodium levels between 121-125 mmol/L warrant extreme caution and potential cessation, particularly if accompanied by rising creatinine 3

Marked Hypovolemia

• Furosemide causes reduction in renal perfusion and worsens azotemia in hypovolemic patients 3
• Clinical signs include decreased skin turgor, hypotension, and tachycardia 2
• The American Association of Nephrology explicitly warns against furosemide use in hypovolemia 3

Severe Hypotension

• Systolic blood pressure <90 mmHg without circulatory support is a contraindication 2
• Furosemide worsens tissue perfusion and can precipitate cardiogenic shock in hypotensive patients 2

Severe Hypokalemia

• Potassium <3 mmol/L mandates stopping furosemide immediately 2
• The drug should be temporarily suspended until potassium is corrected 3

Important Clinical Caveats

Sepsis Without Volume Overload

• Furosemide should not be used in septic patients unless hypervolemia, hyperkalemia, or renal acidosis are present 3
• Risk of inducing or worsening hypovolemia and promoting thrombosis 3

Acute Kidney Injury

• The KDIGO guidelines explicitly recommend against using furosemide to prevent or treat AKI itself (Grade 1B) 2
• Furosemide may only be used in AKI when managing concurrent volume overload, not to improve renal function 2
• Randomized trials demonstrate no benefit and potential increased mortality when used to prevent AKI 2

Hepatic Encephalopathy

• Worsening hepatic encephalopathy in cirrhotic patients requires immediate discontinuation 2, 3

Relative Contraindications Requiring Extreme Caution

Moderate Hyponatremia (126-135 mmol/L)

• Requires intensive electrolyte monitoring if furosemide is continued 3
• Consider dose reduction or temporary cessation 2

Progressive Renal Failure

• Rising creatinine >150 μmol/L (1.7 mg/dL) or increase >120 μmol/L (1.36 mg/dL) from baseline warrants reassessment 3
• In cirrhotic patients with sodium 121-125 mmol/L and rising creatinine, furosemide must be stopped 3

Recent Fluid Resuscitation

• The European Society of Intensive Care Medicine recommends withholding furosemide within 12 hours of last fluid bolus or vasopressor administration 3

Common Clinical Pitfalls

Acidosis

• Severe acidosis is a contraindication to furosemide administration 2

Dialysis-Dependent Renal Failure

• The Society of Critical Care Medicine lists dialysis-dependent renal failure as a contraindication 3

Oliguria with High Creatinine

• Oliguria with serum creatinine >3 mg/dL and urinary indices indicating acute renal failure is a contraindication 3

Incapacitating Muscle Cramps

• In cirrhotic patients, severe muscle cramps require furosemide discontinuation 2