Loop Diuretics


Article Author:
Chris Huxel
Avais Raja


Article Editor:
Michelle Ollivierre-Lawrence


Editors In Chief:
Sherri Murrell


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
10/15/2019 7:22:40 PM

Indications

Loop diuretics have been approved by the Food and Drug Administration (FDA) for treating conditions of edema associated with congestive heart failure, liver cirrhosis, and renal disease, including the nephrotic syndrome.

According to the 2014 ACCF/AHA Guideline for the Management of Heart Failure, patients admitted with heart failure (Stage C) with signs of fluid overload should be treated with intravenous loop diuretics to reduce morbidity. The ACCF/AHA has given a Class I recommendation for the use of diuretics (including loop diuretics) as the first-line treatment of heart failure with reduced left ventricular ejection fraction (HFrEF) and volume overload.[1][2]

The FDA has approved loop diuretics for the use of treating hypertension alone or with the addition of other anti-hypertensives. However, loop diuretics alone are not used for first-line therapy. In 2014, the panel members of the Eighth Joint National Committee (JNC-8) released a report on the management of high blood pressure in adults. JNC-8 made a Grade B recommendation that in the general population, first-line anti-hypertensives should include either ACE inhibitors, ARBs, CCBs, or thiazide diuretics. In several large randomized drug trials, loop diuretics did not provide better outcomes when compared with the first-line drugs.[3] In the American College of Cardiology/American Heart Association Task Force report of clinical practice guidelines, there was a Class I recommendation for the use of diuretics to treat hypertension in adults with heart failure preserved ejection fraction (HFpEF) who presents with symptoms of fluid overload. Diuretic dosing is important in the success of adding other drugs for hypertension in the setting of HFpEF. If the dosing is too low, it can lead to fluid retention. If the dosing is too high, then volume contraction, and result in hypotension and renal injury.[4]

 In cases of hepatic cirrhosis with ascites that do not resolve initially with spironolactone, there is a grade A recommendation for the use of diuretics that can be dosed up to 160 mg/day. In these cases, diuretic administration should typically be in a hospital setting for close monitoring. With the alteration of fluids and electrolytes, the FDA recognizes the need for strict observation as these alterations may precipitate hepatic coma.[5]

Mechanism of Action

Loop diuretics induce its effect by competing with chloride to bind to the Na-K-2Cl (NKCC2) cotransporter at the apical membrane of the thick ascending limb of the loop of Henle and blocking the cotransporter, which inhibits the reabsorption of sodium and chloride. By inhibiting NaCl reabsorption, tonicity in the interstitium decreases, and free water excretion increases as a result. Blocking of the NKCC2 cotransporter makes potassium unable to be reabsorbed back into the lumen, which results in the loss of calcium and magnesium ions.[1]

Administration

Several loop diuretics come in IV and oral forms.

  • Furosemide comes in oral tablet form in 20, 40, and 80 mg dosages. Injectable solutions come in 10 mg/mL doses. Oral solutions come in either 8 or 10 mg/mL doses.
  • Torsemide comes in a tablet form in 5, 10, 20, or 100 mg doses. Injectable solution is 10 mg/mL dosing.
  • Bumetanide comes in oral tablets of 0.5, 1 and 2 mg doses. IV solution is 0.25 mg/mL.
  • Ethacrynic acid is available with oral tablets of 25 mg and in a powder form for injections at 50 mg.

Bioavailability varies between each member of the loop diuretics. Furosemide has an average bioavailability of 50%, while bumetanide and torsemide are closer to 80%.

The half-life for furosemide is 1.5 to 2 hours but can be up to 2.6 hours in those with renal/hepatic dysfunction or heart failure. Bumetanide has a half-life of 1 hour and can be near 1.3 to 1.6 hours in those with renal/hepatic dysfunction or heart failure. Lastly, torsemide is known to have the longest half-life at 3 to 4 hours and can be as long as 5 to 6 hours in patients with renal/hepatic dysfunction or heart failure. All three loops typically have a similar onset of action. Oral administration between the three averages at 30 to 60 minutes.[6][2][7]

Torsemide provides the longest duration of action and can give even greater diuretic effects in patients that have hepatic dysfunction or heart failure.

Adverse Effects

Adverse effects for loops diuretics typically occur from electrolyte imbalances secondary to the diuresis effects which include: hyponatremia, hypokalemia, hypochloremia, hypomagnesemia, metabolic alkalosis, prerenal azotemia, dehydration, hypertriglyceridemia, hypercholesterolemia,  hyperuricemia, gout, restlessness, headache, dizziness, vertigo, postural hypotension, and syncope. Other adverse reactions include skin photosensitivity, interstitial nephritis, tinnitus, ototoxicity, deafness, and in patients with renal failure who receive high doses, myalgias, and muscle soreness.[8]

Thrombocytopenia, aplastic anemia, hemolytic anemia, leukopenia, agranulocytosis, abdominal cramping, anorexia, diarrhea, constipation, urticaria, anaphylaxis, erythema multiforme, exfoliative dermatitis, Steven-Johnson syndrome, toxic epidermal necrolysis, jaundice, pancreatitis, hepatic coma, fever, pneumonitis, pulmonary edema, necrotizing angiitis, blurred vision and impotence have links to diuretic use.[9]

Contraindications

Contraindications to loop diuretics include:

  • Anuria
  • History of hypersensitivity to furosemide, bumetanide or torsemide (or sulfonamides)
  • Hepatic coma
  • Severe states of electrolyte depletion

Monitoring

Prescribers must be cautious with it comes to dosing to achieve diuresis. There is a black box warning that states each loop diuretic is a potent diuretic and at higher dosages, could lead to a profound diuresis with water and electrolyte depletion. Careful medical supervision is necessary as adjustments to these drugs should be according to the patient's needs. Electrolyte disturbances, including hyponatremia, hypochloremic alkalosis, hypokalemia, hypocalcemia, and hypomagnesemia can lead to serious cardiac arrhythmias. Electrolytes should be checked periodically to assess diuretic tolerance.

Ototoxicity can occur with any of the loop diuretics, especially with the concomitant use of aminoglycosides and renal impairment. Furosemide has increased risk for ototoxicity in those with hypoproteinemia (those with nephrotic syndrome). Ethacrynic acid has been known to have a more ototoxic potential than the other members and can lead to permanent sensorineural hearing loss without proper caution of its use, especially concomitantly with another loop diuretic.[10][11][12]

Hyperuricemia secondary to loop diuretic use can result in acute gout attacks or flares.[13]

Caution is necessary for patients known to have a sulfonamide allergy. When taken with a loop diuretic, there is a low potential for cross-allergenicity between the two drugs, although it has not had extensive study. Allergic reactions could include a maculopapular rash, and extra consideration should be given before giving a loop diuretic in patients that have a history of Steven Johnson syndrome or toxic epidermal necrolysis. Since ethacrynic acid is not a sulfonamide derivative like the other members of loop diuretics, it is a safer diuretic to use in a patient that may have a sulfonamide allergy.[14][15]

In those with advanced renal failure with symptoms of fluid overload, physicians should closely monitor fluid status and renal function to prevent the onset of oliguria, BUN, and creatinine increases and azotemia. Close management of aggressive diuresis requires careful surveillance.

Care is necessary when weighing risk vs. reward when considering adding a loop diuretic to a neonate at risk for kernicterus. It is a drug that can displace bilirubin and cause unconjugated hyperbilirubinemia.[16]

Hepatoxicity or those with cirrhosis also require caution as changes in electrolytes and acid/base balance may precipitate hepatic encephalopathy. An aldosterone antagonist or potassium-sparing diuretic may offer adequate diuresis without the risk of electrolyte imbalance.

 Digoxin-diuretic interactions increase the electrolyte imbalances and cardiac arrhythmias noted in several studies. With the setting of hypokalemia, it is known that digoxin toxicity can increase with the administration of a loop diuretic. Studies have shown that loop diuretics carries the greatest risk of digoxin toxicity when compared to thiazides or potassium-sparing diuretics.[17] Patients should not be placed on this combination of drugs.

Diabetic patients are at risk of hyperglycemia when using a loop diuretic. Caution should be taken with blood glucose levels being monitored periodically.

Loop diuretics, especially furosemide, have been used to treat pulmonary edema, severe hypertension in the setting of renal disease and, congestive heart failure in pregnant mothers. Loop diuretics have been given a Grade C for its use in pregnancy. Risk versus rewards should be weighed when considering starting a diuretic with a potential side effect of neonatal kernicterus.[18]

Toxicity

Diuretic toxicity can present in the form of electrolyte imbalances (hyponatremia, hypokalemia, hypocalcemia), acid/base disturbances (hypochloremic alkalosis), and dehydration secondary to excessive diuresis. Care must be taken to check electrolytes while the patient is on a diuretic periodically. Treatment would include rehydration, correction of the acid/base disturbance, and electrolyte replacement. If hypotension is unresolved, pressure support may be required.

Enhancing Healthcare Team Outcomes

Fluid overload states and alternative treatments of hypertension can be treated effectively with loop diuretic use. However, healthcare workers should be wary of their intended uses, side effect profiles, and contraindications. Caution is necessary when regulating which loop diuretic and the dosage chosen for the desired diuresis effect. Aggressive over diuresis can lead to dehydration, electrolyte imbalances, hypotension, and sudden cardiac arrhythmias in more severe cases. Clinicians should include periodic monitoring of blood pressures, fluid status (including weight), serum electrolytes, and renal function in continued diuretic treatments. Goals for diuresis should consist of dosage adjustments as patients progress with their response to the diuretics.

Pharmacists should always verify the dosing of these and all drugs and perform medication reconciliation for drug-drug interactions. Healthcare workers have a responsibility to keep up with current loop diuretic recommendations and provide safe practice to their patients. Nursing can monitor treatment compliance and verify therapy effectiveness as well as monitor for adverse drug reactions. Nursing and pharmacy will report all concerns to the physician and the rest of the interprofessional team, operating collaboratively to achieve optimal therapeutic results. [Level V]


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Loop Diuretics - Questions

Take a quiz of the questions on this article.

Take Quiz
A 65-year-old female presents for increased pedal edema since the last week. She reports being on her feet for 8 hours a day at work. She has a history of hypertension, hyperlipidemia, hypothyroidism, and heart failure with preserved ejection fraction. The patient's daily medications are atorvastatin, losartan, levothyroxine, and bumetanide. On physical exam, the clinician notes pitting pedal edema bilaterally. A 2D echocardiography shows an ejection fraction of 40-45%. While educating the patient on wearing compression stockings and raising her limbs at the end of the day, the clinician adjusts her diuretic dose to twice a day. Appropriate management while monitoring this patient would include which of the following?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 65-year-old male with hypertension, diabetes, and heart failure with reduced ejection fraction presents to the office for increasing dyspnea on exertion for a week. Home medications include metformin, lisinopril, and bumetanide. Vital signs are stable. EKG shows normal sinus rhythm. His last echocardiogram revealed an ejection fraction of 30%. The physical exam includes crackles noted in the bases, positive jugular venous distension and 1+ pitting edema in the lower extremities. Labs include potassium of 3.5 mEq/L, chloride of 98 mEq/L, and a creatinine of 2.6 mg/dL. Which of the following acid-base disorders would be expected to be present in this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 65-year-old male with known problems of heart failure with preserved ejection fraction, hypercholesterolemia, and hypertension presents to the clinic for increased dyspnea on exertion, exercise intolerance, and orthopnea for a week. Home medications include atorvastatin and losartan. Vital signs reveal a blood pressure of 143/93 mmHg, and heart rate 86/min, respiratory rate 12/min, and pulse oximetry of 91% on room air. Physical exam findings reveal jugular venous distension and pitting edema in the bilateral lower extremities. A 2D echocardiogram reveals an ejection fraction of 35% with mild concentric left ventricular hypertrophy. EKG shows normal sinus rhythm. Pertinent labs include a creatinine of 1.2 milligrams per deciliter, glomerular filtration rate of 30 milliliters per minute and normal electrolyte levels. A trial of loop diuretics is initiated. Which of the following findings would expect to be seen?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 65-year-old male presents to the clinic for shortness of breath and fluid overload for the last week. She has a known history of hypertension, diabetes, and coronary artery disease. Medications include metformin, amlodipine, atorvastatin, and aspirin. Past medication allergies include penicillin, trimethoprim-sulfamethoxazole, and ciprofloxacin. His family history is unremarkable. Physical examination shows crackles on auscultation in the bases and 2+ pedal edema bilaterally. An echocardiogram shows an ejection fraction of 35%-40% with mild apical wall hypokinesis. Which of the following medication should be given to this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 65-year-old male presents to the clinic with increasing dyspnea noted to get worse with exertion and bilateral pedal edema for a week. He has a history of chronic kidney disease (CKD), prior cardiovascular accident (CVA) with no residual deficits, cirrhosis, and chronic obstructive pulmonary disease (COPD). Vital signs are blood pressure 115/95 mmHg, heart rate 89 beats per minute, respiratory rate 22 breaths per minute, pulse oximetry of 91% on room air, and a temperature of 98 Fahrenheit. On physical exam, the clinician notes bibasilar crackles and pitting edema of the lower extremities bilaterally. EKG shows normal sinus rhythm. Pertinent labs include sodium 139 millimoles per liter, potassium 4.6 millimoles per liter, chloride 108 millimoles per liter, calcium 10 milligrams per deciliter, phosphorus of 3.1 milligrams per deciliter, creatinine 3.5 milligrams per deciliter, and glomerular filtration rate of 15 mL/min/1.73m2. Which of the following conditions would be a contraindication for the use of a loop diuretic in this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 65-year-old male with hypertension, hyperlipidemia, heart failure with reduced ejection fraction and paroxysmal atrial fibrillation presents to the office for complaints of nausea, vomiting, diarrhea, myalgias and blurred vision for the last week. His medications include amlodipine, furosemide, atorvastatin, digoxin, and warfarin. He reports noticing weakness in his arms and legs at the same time as his other symptoms. He denies chest pain, palpitations, dyspnea, or syncope. Patient reports seeing his provider a week ago and found to have new-onset atrial fibrillation. He reports being started on warfarin. His vitals include a blood pressure of 106/75 mmHg, heart rate of 100/min, a respiratory rate of 12/min, 98% O2 saturation on room air and a temperature of 98 F. He reports seeing a yellowish-green halo when examining his eyes. The cardiovascular exam shows an irregularly irregular rhythm. Lungs are clear to auscultation. Trace bilateral lower extremity edema is noted on the exam. An echocardiogram done two months ago showed an ejection fraction of 40% and moderate left ventricular dysfunction. EKG shows atrial fibrillation with a few premature ventricular contractions (PVCs). Lab results show serum potassium of 3.1 mEq/L. Which combination of medications could be responsible for the patient's symptoms?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 65-year-old male with a history of congestive heart failure, hypertension, and diabetes presents to the office for evaluation of a tender left big toe. The patient noted sudden, severe toe pain that was sharp and has progressively gotten worse over the last two days. The patient denies fever, chills, chest pain, dyspnea, or nausea. His medications include lisinopril, furosemide, metformin, and glyburide. Physical examination reveals a markedly tender and swollen left first metatarsophalangeal joint that is warm to the touch. Vital signs are stable. Lab studies reveal a white cell count of 12 u/L and a uric acid level of 6.8 mg/dL. Synovial joint fluid analysis reveals negative birefringent needle-shaped crystals with no organisms. Which of the following could have led to the patient's condition?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 69-year-old female presents to the emergency department for increasing dyspnea on exertion and nocturnal dyspnea for a week. She reports noticing she cannot get around her house recently like she used to. She also notes having an 8 lb weight gain in the last 2 weeks unintentionally. She has a history of hypertension, diabetes, coronary artery disease, and chronic obstructive pulmonary disease. Vital signs show a heart rate of 107/minute and respiratory rate 22/minute. Physical exam reveals bibasilar crackles, pitting edema, and a 3 cm jugular venous distension. Chest x-ray reveals bibasilar congestion. An echocardiogram reveals an ejection fraction of 40% with mild left ventricular dysfunction. What is the best initial medication for this patient and where in the kidney does it act?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 67-year-old male presents to the emergency department with ringing in his ears for the past 2 hours. His condition worsened after he attempted to stand up that resulted in dizziness and lightheadedness. On the initial intake vitals, the patient's blood pressure is 90/60 mm Hg, heart rate is 110 bpm, the temperature is 37 C and the respiratory rate is 20 breaths per minute. An electrocardiogram shows atrial fibrillation. His physical examination was within normal limits. He has a current medical history of primary hypertension controlled with two antihypertensive medication, one of which was added three days ago by his primary care provider. This is his second emergency department visit in the past 2 months, where he was admitted for an upper respiratory tract infection. Which of the following may be the reason for the patient's presentation?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 70-year male presents to the emergency department with shortness of breath for one hour. He is a known case of systolic heart failure, but he ran out of medication four days ago. His vitals on intake were a blood pressure of 80/60 mm Hg, heart rate of 120 bpm, and respiratory rate of 25 breaths per minute. An emergency chest radiograph was performed that showed a cardiothoracic ratio of 0.8 and blunted costophrenic angles bilaterally. On initial blood testing, there is an elevation in the serum BNP with a normal metabolic panel. The patient undergoes the following procedure exhibited in the image below. He is eventually admitted and administered furosemide intravenously along with nitroglycerin, morphine, and oxygen. While monitoring this patient, which of the following metabolic profile is expected if the patient's medication is not appropriately titered?

(Move Mouse on Image to Enlarge)
  • Image 4046 Not availableImage 4046 Not available
    Contributed by C. H. Chen, S. Y. Lee et al. ( CC BY 2.0 https://creativecommons.org/licenses/by/2.0/deed.en )
Attributed To: Contributed by C. H. Chen, S. Y. Lee et al. ( CC BY 2.0 https://creativecommons.org/licenses/by/2.0/deed.en )



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Loop Diuretics - References

References

Ellison DH,Felker GM, Diuretic Treatment in Heart Failure. The New England journal of medicine. 2017 Nov 16     [PubMed]
Wang DJ,Gottlieb SS, Diuretics: still the mainstay of treatment. Critical care medicine. 2008 Jan     [PubMed]
James PA,Oparil S,Carter BL,Cushman WC,Dennison-Himmelfarb C,Handler J,Lackland DT,LeFevre ML,MacKenzie TD,Ogedegbe O,Smith SC Jr,Svetkey LP,Taler SJ,Townsend RR,Wright JT Jr,Narva AS,Ortiz E, 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014 Feb 5     [PubMed]
Whelton PK,Carey RM,Aronow WS,Casey DE Jr,Collins KJ,Dennison Himmelfarb C,DePalma SM,Gidding S,Jamerson KA,Jones DW,MacLaughlin EJ,Muntner P,Ovbiagele B,Smith SC Jr,Spencer CC,Stafford RS,Taler SJ,Thomas RJ,Williams KA Sr,Williamson JD,Wright JT Jr, 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension (Dallas, Tex. : 1979). 2018 Jun     [PubMed]
Moore KP,Aithal GP, Guidelines on the management of ascites in cirrhosis. Gut. 2006 Oct     [PubMed]
Wargo KA,Banta WM, A comprehensive review of the loop diuretics: should furosemide be first line? The Annals of pharmacotherapy. 2009 Nov     [PubMed]
Preobrazhenskiń≠ DV,Sidorenko BA,Tarykina EV,Batyraliev TA,Marenich AV, [Torasemide--new generation loop diuretic: clinical pharmacology and therapeutic application]. Kardiologiia. 2006     [PubMed]
Qavi AH,Kamal R,Schrier RW, Clinical Use of Diuretics in Heart Failure, Cirrhosis, and Nephrotic Syndrome. International journal of nephrology. 2015     [PubMed]
Sica DA,Carter B,Cushman W,Hamm L, Thiazide and loop diuretics. Journal of clinical hypertension (Greenwich, Conn.). 2011 Sep     [PubMed]
Jiang M,Karasawa T,Steyger PS, Aminoglycoside-Induced Cochleotoxicity: A Review. Frontiers in cellular neuroscience. 2017     [PubMed]
Schwartz GH,David DS,Riggio RR,Stenzel KH,Rubin AL, Ototoxicity induced by furosemide. The New England journal of medicine. 1970 Jun 18     [PubMed]
Rybak LP, Ototoxicity of ethacrynic acid (a persistent clinical problem). The Journal of laryngology and otology. 1988 Jun     [PubMed]
    [PubMed]
    [PubMed]
    [PubMed]
Walker PC, Neonatal bilirubin toxicity. A review of kernicterus and the implications of drug-induced bilirubin displacement. Clinical pharmacokinetics. 1987 Jul     [PubMed]
Wang MT,Su CY,Chan AL,Lian PW,Leu HB,Hsu YJ, Risk of digoxin intoxication in heart failure patients exposed to digoxin-diuretic interactions: a population-based study. British journal of clinical pharmacology. 2010 Aug     [PubMed]
Turmen T,Thom P,Louridas AT,LeMorvan P,Aranda JV, Protein binding and bilirubin displacing properties of bumetanide and furosemide. Journal of clinical pharmacology. 1982 Nov-Dec     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Nurse-Elder Adult Care. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Nurse-Elder Adult Care, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Nurse-Elder Adult Care, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Nurse-Elder Adult Care. When it is time for the Nurse-Elder Adult Care board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Nurse-Elder Adult Care.