Diusemide is indicated for the management of fluid retention and for the management of mild to moderate hypertension, either alone or as an adjuvant.

(See Section 5.2 Pharmacokinetic Properties-Special patient population)

 

General: The dose used must be the lowest that is sufficient to achieve the desired effect.

Diusemide has an exceptionally wide therapeutic range, the effect being proportional to the dosage. Diusemide is best given as a single dose either daily or on alternate days.

 

The usual initial daily dose is 40 mg. This may require adjustment until the effective dose is achieved as a maintenance dose. In mild cases, 20 mg daily or 40 mg on alternate days may be sufficient, whereas in cases of resistant oedema, daily doses of 80 mg and above may be used as one or two doses daily, or intermittently. Severe cases may require gradual titration of the furosemide dosage up to 600mg daily. The recommended maximum daily dose of furosemide administration is 1500 mg.

 

Children: Oral doses for children range from 1 to 3mg/kg body weight daily up to a maximum total dose of 40 mg/day.

 

Elderly: The dosage recommendations for adults apply, but in the elderly furosemide is eliminated more slowly in general. Dosage should be titrated  until the required response is achieved.

Patients with hypovolaemia or dehydration, anuria or renal failure with anuria not responding to furosemide, renal failure as a result of poisoning by nephrotoxic or hepatotoxic agents or renal failure associated with hepatic coma, severe hypokalaemia, severe hyponatraemia, pre-comatose and comatose states associated with hepatic encephalopathy and breast feeding women. Hypersensitivity to furosemide or any of the excipients of Diusemide. Patients allergic to sulphonamides may show cross-sensitivity to furosemide.

Too vigorous diuresis may cause orthostatic hypotension or acute hypotensive episodes.

 

Where indicated, steps should be taken to correct hypotension or hypovolaemia before commencing therapy.

 

Regular monitoring of serum sodium, potassium and creatinine is generally recommended during furosemide therapy; particularly close monitoring is required in patients at high risk of developing electrolyte imbalances or in case of significant additional fluid loss. Hypovolaemia or dehydration as well as any significant electrolyte and acid-base disturbances must be corrected. This may require temporary discontinuation of furosemide.

 

Urinary output must be secured. In patients with a partial obstruction of urinary outflow increased production of urine may provoke or aggravate complaints. These patients require careful monitoring. Patients with partial obstruction of urinary outflow, for example patients with prostatic hypertrophy or impairment of micturition have an increased risk of developing acute retention and require careful monitoring.

 

Particularly careful monitoring is necessary in:

• patients with hypotension.
• patients who are at risk from a pronounced fall in blood pressure.
• patients with latent or manifest diabetes. Furosemide may necessitate adjustment of control by hypoglycaemic agents in cases of diabetes mellitus.
• patients with gout
• patients with hepatorenal syndrome
• patients with hypoproteinaemia, e.g. associated with nephritic syndrome (the effect of furosemide may be weakened and its ototoxicity potentiated). Cautious dose titration is required.
• premature infants (possible development nephrocalcinosis nephrolithiasis; renal function must be monitored and renal ultrasonography performed).

The use of diuretics is considered to be unsafe in acute porphyria therefore caution should be exercised.

 

Concomitant use with risperidone

In risperidone placebo controlled trials in elderly patients with dementia, a higher incidence  of   mortality  was   observed   in   patients   treated   with   furosemide  plus risperidone when compared to patients treated with risperidone alone or furosemide alone. Cautions should be exercised and the risks and benefits of this combination or co- treatment should be considered prior to the decision to use. Dehydration should be avoided.

 

Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.

The concomitant administration of this preparation with cardiac glycosides or hypotensive agents may necessitate adjustment of the dosage of those drugs.

 

The harmful effects of nephrotoxic drugs on the kidney may be increased.

 

Impairment of renal function may develop in patients receiving treatment with furosemide and high doses of certain cephalosporins.

 

Oral furosemide and sucralfate must not be taken within 2 hours of each other because sucralfate decreases the absorption of furosemide from the intestine and so reduces its effect.

 

Corticosteroids, corticotrophin and amphotericin  B,  also cause potassium loss and severe potassium depletion may occur when administered  concurrently with furosemide.

 

Carbenoxolone, liquorice in large amounts, B₂ sympathomimetics, prolonged use of laxatives, reboxetine and amphotericin may increase the risk of developing hypokalaemia.

 

Corticosteroids administered concurrently may cause sodium retention.

 

If antihypertensive agents, diuretics or other drugs, with blood-pressure-lowering potential are given concomitantly with furosemide, a more pronounced fall in blood pressure must be anticipated.

 

Concomitant administration of carbamazepine or aminoglutethimide may increase the risk of hyponatraemia.

 

Furosemide decreases the excretion of lithium salts and may cause increased serum lithium levels, resulting in increased lithium toxicity, including increased risk of cardiotoxic and neurotoxic effects of lithium. Therefore, it is recommended that lithium levels are carefully monitored in patients receiving this combination.

 

Concomitant use of ciclosporin A and furosemide is associated with increased risk of gouty arthritis secondary to furosemide-induced hyperuricaemia and cyclosporine impairment of renal urate excretion.

 

Patients who were at high risk for radiocontrast nephropathy treated with furosemide experienced a higher incidence of deterioration in renal function after receiving radiocontrast compared to high-risk patients who received only intravenous hydration prior to receiving radiocontrast.

 

Patients who are receiving diuretics may suffer severe hypotension and deterioration in renal  function,  including  cases  of  renal  failure,  especially  when  an  angiotensin converting enzyme inhibitor (ACE inhibitor) or angiotensin II receptor antagonist is given for the first time or for the first time in an increased dose. Consideration must be given to interrupting the administration of furosemide temporarily or at least reducing the dose of furosemide for three days before starting treatment with, or increasing the dose of, an ACE inhibitor or angiotensin II receptor antagonist.

 

Concomitant administration of non-steroidal anti-inflammatory drugs including acetylsalicyclic acid and Indomethacin may reduce the effect of furosemide. In patients with dehydration or hypovolaemia, non-steroidal anti-inflammatory drugs may cause acute renal failure. Salicylate toxicity may be increased by furosemide.

 

Furosemide may potentiate the ototoxicity of aminoglycosides and other ototoxic drugs. Since this may lead to irreversible damage, these drugs must only be used with furosemide if there are compelling medical reasons.

 

There is a risk of ototoxic effects if cisplatin and furosemide are given concomitantly. In addition, nephrotoxicity of cisplatin may be enhanced if furosemide is not given in low doses (e.g. 40 mg in patients with normal renal function) and with positive fluid balance when used to achieve forced diuresis during cisplatin treatment.

 

Some electrolyte disturbances (e.g. hypokalaemia, hypomagnesaemia) may increase the toxicity of certain other drugs (e.g. digitalis preparations and drugs inducing QT interval prolongation syndrome).

 

Attenuation of the effect of furosemide may occur following concurrent administration of phenytoin.

 

Severe diuresis may occur if metolazone is administered concomitantly.

 

Probenecid, methotrexate and other drugs which, like furosemide, undergo significant renal tubular secretion may reduce the effect of furosemide. Conversely, furosemide may decrease renal elimination of these drugs. In case of high-dose treatment (in particular, of both furosemide and the other drugs), this may lead to increased serum levels and an increased risk of adverse effects due to furosemide or the concomitant medication.

 

The effects of antidiabetic drugs and blood–pressure increasing sympathomimetics (e.g. epinephrine, norepinephrine) may be reduced. The effects of curare-type muscle relaxants or of theophylline may be increased.

 

Risperidone: Caution should be exercised and the risks and benefits of the combination or co-treatment with furosemide should be considered prior to the decision to use (see section 4.4).

Furosemide crosses the placental barrier. It must not be given during pregnancy unless there are compelling medical reasons. Treatment during pregnancy requires monitoring of foetal growth.

 

Furosemide passes into breast milk and may inhibit lactation. Women must not breast- feed if they are treated with furosemide.

Reduced mental alertness may impair ability to drive or operate dangerous machinery.

The frequencies are derived from literature data referring to studies where furosemide is  used  in  a  total  of  1387  patients,  at  any  dose  and  in  any  indication.  When  the frequency category for the same ADR was different, the highest frequency category was selected.

 

The following CIOMS frequency rating is used, when applicable:

Very common ≥10%; Common ≥1 and <10%; Uncommon ≥0.1 and <1%; Rare ≥0.01 and <0.1%; Very rare <0.01%; Unknown (cannot be estimated from available data).

 

Metabolism and nutrition disorders

Very Common              electrolyte disturbances (including symptomatic) dehydration and hypovolaemia, especially in elderly patients. Blood  creatinine increased, blood triglyceride increased.

Common                      hyponatremia, hypochloremia, hypokalaemia, blood cholesterol increased. Blood uric acid increased and attacks of gout, urine volume increased.

Uncommon                  glucose tolerance impaired.

 

Not known                   hypocalcemia, hypomagnesemia, blood urea increased , metabolic alkalosis

 

Vascular Disorders

Very Common             Hypotension including orthostatic hypotension.

Rare                               vasculitis.

Not known                   thrombosis.

 

Renal and urinary disorders

Common                     urine volume increased

Rare                            tubulointerstitial nephritis

Not known                urine sodium increased, urine chloride increase, urine retention (in patients with a partial obstruction of urinary outflow, see  section 4.4), nephrocalcinosis/nephrolithiasis in premature infants (see section 4.4), renal failure (see section 4.5)

 

Gastrointestinal disorders

Uncommon               nausea,

Rare                            vomiting, diarrhoea.

Very Rare                   pancreatitis acute

 

Hepatobiliary disorders

Very Rare                    cholestasis, transaminases increased

 

Ear and labyrinth disorders

Uncommon                 hearing disorders,

Very Rare                      tinnitus.

 

Skin and subcutaneous tissue disorders

Uncommon                  pruritus, urticaria, rashes, dermatitis bullous, erythema multiforme, pemphigoid, dermatitis exfoliative, purpura,                                                                   photosensitivity reaction

Not known                   Stevens-Johnson  syndrome,  toxic  epidermal  necrolysis,  AGEP (acute generalized exanthematous pustulosis) and DRESS (Drug Rash with Eosinophilia and Systemic Symptoms).

 

Immune system disorders

Rare                            severe anaphylactic or anaphylactoid reactions.

 

Nervous system disorders

Rare                            paraesthesiae.

Common                   hepatic encephalopathy in patients with hepatocellular insufficiency. (see section 4.3)

 

Blood and the lymphatic system disorders

Common                       haemoconcentration.

Uncommon                  thrombocytopenia

Rare                               leucopoenia, eosinophilia

Very rare                       agranulocytosis, aplastic anaemia, haemolytic anaemia.

 

Congenital and familiar/genetic disorders

Not known                   increased risk of persistence of patent ductus arteriosus when furosemide is administered to premature infants during the first weeks of life.

 

General disorders and administration site conditions

Not known                   following intramuscular injection, local reactions such as pain.

Rare                              fever

The clinical picture in acute or chronic overdose depends primarily on the extent and consequences of electrolyte and fluid loss, e.g. hypovolaemia, dehydration, haemoconcentration, cardiac arrhythmias due to excessive diuresis. Symptoms of these disturbances include severe hypotension (progressing to shock), acute renal failure, thrombosis, delirious states, flaccid paralysis, apathy and confusion.

 

Treatment should therefore be aimed at fluid replacement and correction of the electrolyte imbalance. Together with the prevention and treatment of serious complications resulting from such disturbances and of other effects on the body, this corrective action may necessitate general and specific intensive medical monitoring and therapeutic measures.

 

No specific antidote to furosemide is known. If ingestion has only just taken place, attempts may be made to limit further systemic absorption of the active ingredient by measures such as gastric lavage or those designated to reduce absorption (e.g., activated charcoal).

 

 

The evidence from many experimental studies suggests that furosemide acts along the entire nephron with the exception of the distal exchange site. The main effect in on the ascending limb of the loop of Henle with a complex effect on renal circulation. Blood- flow is diverted from the juxta-medullary region to the outer cortex. The principle renal action of furosemide is to inhibit active chloride transport in the thick ascending limb. Re-absorption of sodium chloride from the nephron is reduced and a hypotonic or isotonic urine produced.

 

It has been established that prostaglandin (PG) biosynthesis and the renin-angiotensin system are affected by furosemide administration and that furosemide alters the renal permeability of the glomerulus to serum proteins.

 

Furosemide is a weak carboxylic acid which exists mainly in the dissociated form in the gastrointestinal tract. Furosemide is rapidly but incompletely absorbed (60-70%) on oral administration and its effect is largely over within four hours. The optimal absorption site is the upper duodenum at pH 5.0. Regardless of route of administration , 69-97% of activity from a radio-labelled dose is excreted in the first four hours after the drug is given. Furosemide is bound to plasma albumin and little biotransformation takes place.

 

Furosemide is mainly eliminated via the kidneys (80-90%); a small fraction of the dose undergoes biliary elimination and 10-15% of the activity can be recovered from the faeces.

 

a) In renal/hepatic impairment

Where liver disease is present, biliary elimination is reduced up to 50%. Renal impairment has little effect on the elimination rate of Diusemide, but less than 20% residual renal function increases the elimination time.

 

b) The elderly

The elimination of furosemide is delayed in the elderly where a certain degree of renal impairment is present.

 

c) New born

A sustained diuretic effect is seen in the newborn, possibly due to immature tubular function.

No further information other than that which is contained in other sections of the Summary of Product Characteristics.

- Lactose;

- Maize starch;

- Sodiumstarch glycolate;

- Colloidal silicone dioxide;

- Magnesium state.

None.

48 months.

Store below 30°C, away from light.

 

PVC amber blister with Aluminium foil.

Pack size: 30 tablet.

No special requirements.