Bumetanide

Generic Name

Bumetanide

Brand Names

Burinex

Bumex

Generic formulations widely available across different countries

Drug Class

Loop diuretic

Sulfonamide derivative

High-ceiling diuretic

Mechanism of Action

Bumetanide acts on the ascending limb of the loop of Henle in the nephron

It inhibits the Na⁺-K⁺-2Cl⁻ cotransporter (NKCC2), leading to a significant increase in the excretion of sodium, chloride, and water

It causes a rapid and profound diuretic effect, reducing plasma volume and extracellular fluid

It also leads to excretion of potassium, calcium, and magnesium

Its onset of action is rapid, with peak effect within 30 to 90 minutes after oral administration and even faster with intravenous use

It is about 40 times more potent than furosemide on a per milligram basis

Indications

Heart failure with volume overload

Acute pulmonary edema

Hepatic cirrhosis with ascites

Renal impairment with fluid retention

Hypertension (not first-line; used in resistant cases)

Hypercalcemia (off-label use, with IV saline)

Nephrotic syndrome

Fluid overload in intensive care or dialysis settings

Dosing and Administration

Oral Use

Initial: 0.5 mg to 1 mg once or twice daily

May increase at 4- to 5-hour intervals if diuresis is inadequate

Maximum oral dose: 10 mg/day in divided doses

Intravenous (IV) Use

0.5 to 1 mg IV over 1–2 minutes

May repeat in 2 to 3 hours if necessary

Continuous infusion: 0.5 to 2 mg/hour in resistant fluid overload

Monitor fluid balance closely

Pediatric Use

Not routinely used in children

May be used under specialist supervision at weight-based doses

Elderly

Start with lower doses

Monitor electrolytes and renal function frequently

Renal Impairment

Higher doses may be required in renal failure

Still effective when glomerular filtration rate (GFR) is significantly reduced

Monitor creatinine, urine output, and electrolytes closely

Hepatic Impairment

May be used with aldosterone antagonists in ascites

Caution with risk of hepatic encephalopathy due to hypokalemia

Contraindications

Anuria (complete absence of urine production)

Severe electrolyte depletion (especially hypokalemia, hyponatremia)

Hypersensitivity to bumetanide or other sulfonamides

Hepatic coma or precoma in decompensated cirrhosis (without correction of electrolyte imbalance)

Severe hypotension

Precautions

Risk of profound diuresis, leading to dehydration and electrolyte depletion

Monitor potassium and magnesium frequently

Can worsen or cause renal impairment

Caution in patients with gout due to increased uric acid levels

Caution in diabetic patients; may affect glucose tolerance

Photosensitivity and skin reactions reported

Hearing loss (ototoxicity) especially with rapid IV administration or concurrent aminoglycoside use

Careful dose titration in elderly and those with compromised renal function

Adverse Effects

Common

Hypokalemia

Hyponatremia

Hypocalcemia

Hypomagnesemia

Increased uric acid (hyperuricemia)

Metabolic alkalosis

Dizziness

Headache

Muscle cramps

Orthostatic hypotension

Dehydration

Less Common

Increased serum creatinine and BUN

Elevated blood glucose

Ototoxicity (especially with rapid IV use)

Photosensitivity

Rash

Nausea

Fatigue

Rare but Serious

Severe electrolyte imbalance

Acute kidney injury

Thrombocytopenia

Interstitial nephritis

Anaphylactic reactions

Stevens-Johnson syndrome (extremely rare)

Pregnancy and Lactation

Pregnancy

Category C

Should be avoided unless absolutely necessary

May reduce placental perfusion

Use only when benefit clearly outweighs risk

Lactation

Unknown if excreted in breast milk

Avoid or use cautiously; may cause fluid/electrolyte imbalance in infant

Use in Special Populations

Geriatrics

More prone to dehydration and electrolyte abnormalities

Lower initial doses recommended

Frequent monitoring required

Pediatrics

Off-label use under specialist care for fluid overload

Careful dose calculation based on weight

Renal Impairment

Retains efficacy at low GFR

Dose adjustment and closer monitoring required

Hepatic Disease

Caution with electrolyte correction

Use in combination with spironolactone or other potassium-sparing agents to reduce risk of encephalopathy

Drug Interactions

Aminoglycosides (e.g. gentamicin)

Increased risk of ototoxicity and nephrotoxicity

Digoxin

Hypokalemia enhances digoxin toxicity risk

ACE Inhibitors/ARBs

Risk of excessive hypotension and renal impairment

NSAIDs

Reduce diuretic efficacy, blunt natriuresis

Increase risk of renal dysfunction

Lithium

Decreased renal clearance of lithium

Increased lithium toxicity risk

Corticosteroids

Additive risk of hypokalemia

Other Diuretics (e.g., thiazides)

Additive effect on fluid and electrolyte loss

Used cautiously in combination for resistant edema

Metformin

Risk of lactic acidosis increases with volume depletion

Monitoring Parameters

Serum electrolytes: potassium, sodium, magnesium, calcium

Serum creatinine and BUN

Blood pressure and heart rate

Daily weight and urine output

Signs of volume depletion (dry mucosa, low BP, fatigue)

Blood glucose in diabetic patients

Uric acid levels in patients with gout

Hearing function during high-dose IV therapy

Formulations

Tablets: 0.5 mg, 1 mg, 2 mg

Oral solutions: available in select markets

IV injection: 0.25 mg/mL, 1 mg/mL

Multidose vials or single-use ampoules

Patient Counseling Points

Take in the morning to avoid nocturia

Drink adequate fluids but avoid excessive intake

Report symptoms of dizziness, muscle cramps, dry mouth, palpitations

Do not use potassium supplements unless prescribed

Monitor weight daily; notify provider of sudden changes

Use sunscreen to reduce risk of photosensitivity

If diabetic, monitor blood glucose more frequently

Avoid NSAIDs unless advised by a healthcare provider

Keep scheduled blood tests and follow-up appointments

Rise slowly from sitting to avoid lightheadedness from low blood pressure