Furosemide Contraindications
Furosemide is absolutely contraindicated in patients with anuria and in those with a history of hypersensitivity to furosemide. 1, 2
Absolute Contraindications
FDA-Mandated Contraindications
- Anuria: Furosemide must not be used in patients with complete absence of urine output, as the drug requires delivery to the renal tubules to exert its diuretic effect 1, 2
- Hypersensitivity: Any documented allergic reaction or hypersensitivity to furosemide is an absolute contraindication to its use 1, 2
Critical Clinical Contraindications from Guidelines
Severe Hypovolemia and Hypotension
- Furosemide should not be used in patients with marked hypovolemia, as it causes further reduction in renal perfusion and can precipitate azotemia 3
- Do not administer furosemide when systolic blood pressure is <90-100 mmHg without circulatory support, as it will worsen hypoperfusion and potentially precipitate cardiogenic shock 4, 5
Severe Electrolyte Disturbances
- Severe hyponatremia (serum sodium <120-125 mmol/L): Stop furosemide immediately and consider volume expansion 3, 4
- Severe hypokalemia (<3 mmol/L): Furosemide must be temporarily suspended until potassium is corrected 3, 4
Sepsis Without Specific Indications
- Furosemide should not be used in patients with sepsis unless there is documented hypervolemia, hyperkalemia, and/or renal acidosis, due to risk of inducing or worsening hypovolemia and promoting thrombosis 3
Relative Contraindications Requiring Extreme Caution
Recent Hemodynamic Instability
- Do not give furosemide within 12 hours of last fluid bolus or vasopressor administration 3
- Patients must be off vasopressors for ≥12 hours and hemodynamically stable with mean arterial pressure ≥60 mmHg before initiating furosemide 3
Dialysis-Dependent Renal Failure
- Furosemide must be withheld in patients with dialysis-dependent renal failure or oliguria with serum creatinine >3 mg/dL and urinary indices indicating acute renal failure 3
Altered Mental Status in Specific Contexts
- When considering combination therapy with tolvaptan, avoid furosemide in patients with altered mental state who cannot drink adequate fluids, due to risk of severe dehydration and hypernatremia 5
Important Clinical Caveats
Common Pitfall to Avoid
- Never administer furosemide to hypotensive patients expecting it to improve hemodynamics—it causes further volume depletion and worsens tissue perfusion, potentially leading to cardiogenic shock 4
Monitoring Requirements Before Administration
- Verify systolic blood pressure ≥90-100 mmHg 4
- Check serum sodium (must be >120-125 mmol/L) 3, 4
- Confirm adequate tissue perfusion and absence of marked hypovolemia 4
- Ensure patient is not anuric 1, 2
Special Population Considerations
- In cirrhotic patients, additional contraindications include active GI hemorrhage, severe hepatic encephalopathy, and uncorrected electrolyte abnormalities, which must be addressed before starting furosemide 4
- In acute kidney injury, furosemide should only be used for volume overload management, not for AKI prevention or treatment, as it does not improve renal function and may increase mortality when used inappropriately 3