FUROSEMIDE & DIGOXIN

A Drug Study Presented to

The Faculty of the Nursing Department
Milagrosa Cadida Caburnay, RN, MN

In Partial Fulfillment of
the fulfillments in NCM- 209
PEDIATRIC NURSING ROTATION

By
Peter John Paul N. Dapitanon, St.N

April 22, 2020

Generic Name

Furosemide

Brand Name Lasix

Classification Loop Diuretic

Mode of Action Furosemide inhibits reabsorption of Na and Cl mainly in the

medullary portion of the ascending loop of Henle. Excretion of K and
ammonia is also increased while uric acid excretion is reduced. It
increases plasma-renin activity, plasma-norepinephrine and
plasma-arginine-vasopressin concentrations.

Dose / Route Intravenous

Acute pulmonary oedema
Adult: 40 mg via slow inj over 1-2 minutes. If no adequate response
within 1 hour, a further 80 mg may be given via slow IV inj over 1-2
minutes.

Oral
Oedema associated with heart failure
Adult: Initially, 40 mg daily, may reduce to 20 mg daily or 40 mg on
alternate days. In some cases, 80 mg or more daily in divided doses
may be required.
Elderly: Initially, 20 mg and titrate upward if needed.

Oral
Hypertension
Adult: 40-80 mg daily, alone or in combination w/ other
antihypertensives.

Parenteral
Oedema associated with heart failure
 Adult: 20-50 mg via IM or slow IV inj, may increase by increments of
20 mg 2 hrly. Doses >50 mg must be given via slow IV infusion.
Max: 1,500 mg daily.
Child: 0.5-1.5 mg/kg daily. Max: 20 mg daily.

Indication Indicated in adults and pediatric patients for the treatment of edema
associated with congestive heart failure, cirrhosis of the liver, and
renal disease, including the nephrotic syndrome.

Contraindicatio Hypersensitivity to furosemide and sulfonamides. Anuria or renal

n failure, Addison's disease, hypovolaemia or dehydration,
precomatose state associated w/ liver cirrhosis.

Side Effects  nausea or vomiting.

 diarrhea.
 constipation.
 stomach cramping.
 feeling like you or the room is spinning (vertigo)
 dizziness.
 headache.
 blurred vision.

Adverse Effects  CNS: blurred vision, dizziness, headache, vertigo

 CV: hypotension
 Derm: ERYTHEMA MULTIFORME, STEVENS-JOHNSON
SYNDROME, TOXIC EPIDERMAL NECROLYSIS,
photosensitivity, pruritis, rash, urticaria
 EENT: hearing loss, tinnitus
 Endo: hypercholesterolemia, hyperglycemia,
hypertriglyceridemia, hyperuricemia
 F and E: dehydration, hypocalcemia, hypochloremia,
hypokalemia, hypomagnesemia, hyponatremia, hypovolemia,
metabolic alkalosis
 GI: anorexia, constipation, diarrhea, dry mouth, dyspepsia, ↑
liver enzymes, nausea, pancreatitis, vomiting
  GU: ↑ BUN, excessive urination, nephrocalcinosis
 Hemat: APLASTIC ANEMIA, AGRANULOCYTOSIS,
hemolytic anemia, leukopenia, thrombocytopenia
 MS: muscle cramps
 Neuro: paresthesia
 Misc: fever

Drug  ↑ risk of hypotension with antihypertensives, nitrates, or

Interactions acute ingestion of alcohol .
 ↑ risk of hypokalemia with other diuretics, amphotericin B,
stimulant laxatives, and corticosteroids .
 Hypokalemia may ↑ risk of digoxin toxicity and ↑ risk of
arrhythmia in patients taking drugs that prolong the QT
interval.
 ↓ lithium excretion, may cause lithium toxicity.
 ↑ risk of ototoxicity with aminoglycosides or cisplatin .
 ↑ risk of nephrotoxicity with cisplatin .
 NSAIDS ↓ effects of furosemide.
 May ↑ risk of methotrexate toxicity.
 ↓ effects when given at same time as sucralfate,
cholestyramine, or colestipol .
 ↑ risk of salicylate toxicity (with use of high-dose salicylate
therapy).
 Concurrent use with cyclosporine may ↑ risk of gouty
arthritis.

Nursing 1. Assess fluid status. Monitor daily weight, intake and output
Interventions ratios, amount and location of edema, lung sounds, skin
turgor, and mucous membranes. Notify health care
professional if thirst, dry mouth, lethargy, weakness,
hypotension, or oliguria occurs.
2. Monitor BP and pulse before and during administration.
Monitor frequency of prescription refills to determine
compliance in patients treated for hypertension.
3. Assess patients receiving digoxin for anorexia, nausea,
vomiting, muscle cramps, paresthesia, and confusion.
Patients taking digoxin are at increased risk of digoxin toxicity
because of the potassium-depleting effect of the diuretic.
Potassium supplements or potassium-sparing diuretics may
be used concurrently to prevent hypokalemia.
4. Assess patients receiving digoxin for anorexia, nausea,
vomiting, muscle cramps, paresthesia, and confusion.
Patients taking digoxin are at increased risk of digoxin toxicity
because of the potassium-depleting effect of the diuretic.
Potassium supplements or potassium-sparing diuretics may
be used concurrently to prevent hypokalemia.
5. Assess patient for skin rash frequently during therapy.
Discontinue furosemide at first sign of rash; may be life-
threatening. Stevens-Johnson syndrome, toxic epidermal
necrolysis, or erythema multiforme may develop. Treat
symptomatically; may recur once treatment is stopped.
6. Instruct patient to take furosemide as directed. Take missed
doses as soon as possible; do not double doses.
7. Caution patient to change positions slowly to minimize
orthostatic hypotension. Caution patient that the use of
alcohol, exercise during hot weather, or standing for long
periods during therapy may enhance orthostatic hypotension.
8. Advise patient to contact health care professional
immediately if rash, muscle weakness, cramps, nausea,
dizziness, numbness, or tingling of extremities occurs.
9. Emphasize the importance of routine follow-up examinations.
Generic Name

Digoxin

Brand Name Lanoxin

Classification Antiarrhythmics

Mode of Action  Digoxin is a cardiac glycoside which has positive inotropic

activity characterised by an increase in the force of
myocardial contraction. It also reduces the conductivity of the
heart through the atrioventricular (AV) node. Digoxin also
exerts direct action on vascular smooth muscle and indirect
effects mediated primarily by the autonomic nervous system
and an increase in vagal activity.
 Increases the force of myocardial contraction.
 Prolongs refractory period of the AV node.
 Decreases conduction through the SA and AV nodes.

Dose / Route  IV IM (Adults) Digitalizing dose– 0.5–1 mg given as 50% of

the dose initially and one quarter of the initial dose in each of
2 subsequent doses at 6–12 hr intervals.
 IV IM (Children >10 yr) Digitalizing dose– 8–12 mcg/kg
given as 50% of the dose initially and one quarter of the initial
dose in each of 2 subsequent doses at 6–12 hr intervals.
 IV IM (Children 5–10 yr) Digitalizing dose– 15–30 mcg/kg
given as 50% of the dose initially and one quarter of the initial
dose in each of 2 subsequent doses at 6–12 hr intervals.
 IV IM (Children 2–5 yr) Digitalizing dose– 25–35 mcg/kg
given as 50% of the dose initially and one quarter of the initial
dose in each of 2 subsequent doses at 6–12 hr intervals.
 IV IM (Children 1–24 mo) Digitalizing dose– 30–50
mcg/kg given as 50% of the dose initially and one quarter of
the initial dose in each of 2 subsequent doses at 6–12 hr
 intervals.
 IV IM (Infants –full term) 20–30 mcg/kg given as 50% of the
dose initially and one quarter of the initial dose in each of 2
subsequent doses at 6–12 hr intervals.
 IV IM (Infants –premature) Digitalizing dose– 15–25
mcg/kg given as 50% of the dose initially and one quarter of
the initial dose in each of 2 subsequent doses at 6–12 hr
intervals.
 PO (Adults) Digitalizing dose– 0.75–1.5 mg given as 50%
of the dose initially and one quarter of the initial dose in each
of 2 subsequent doses at 6–12 hr intervals. Maintenance
dose– 0.125–0.5 mg/day depending on patient's lean body
weight, renal function, and serum level.
 PO Geriatric Patients Initial daily dose should not exceed
0.125 mg.
 PO (Children >10 yr) Digitalizing dose– 10–15 mcg/kg
given as 50% of the dose initially and one quarter of the initial
dose in each of 2 subsequent doses at 6–12 hr intervals.
Maintenance dose– 2.5–5 mcg/kg given daily as a single
dose.
 PO (Children 5–10 yr) Digitalizing dose– 20–35 mcg/kg
given as 50% of the dose initially and one quarter of the initial
dose in each of 2 subsequent doses at 6–12 hr intervals.
Maintenance dose– 5–10 mcg/kg given daily in 2 divided
doses.
 PO (Children 2–5 yr) Digitalizing dose– 30–40 mcg/kg
given as 50% of the dose initially and one quarter of the initial
dose in each of 2 subsequent doses at 6–12 hr intervals.
Maintenance dose– 7.5–10 mcg/kg given daily in 2 divided
doses.
 PO (Children 1–24 mo) Digitalizing dose– 35–60 mcg/kg
given as 50% of the dose initially and one quarter of the initial
dose in each of 2 subsequent doses at 6–12 hr intervals.
 Maintenance dose– 10–15 mcg/kg given daily in 2 divided
doses.
 PO (Infants –full term) Digitalizing dose– 25–35 mcg/kg
given as 50% of the dose initially and one quarter of the initial
dose in each of 2 subsequent doses at 6–12 hr intervals.
Maintenance dose– 6–10 mcg/kg given daily in 2 divided
doses.
 PO (Infants –premature) Digitalizing dose– 20–30 mcg/kg
given as 50% of the dose initially and one quarter of the initial
dose in each of 2 subsequent doses at 6–12 hr intervals.
Maintenance dose– 5–7.5 mcg/kg given daily in 2 divided
doses.

Indication  Heart failure.

 Atrial fibrillation and atrial flutter (slows ventricular rate).
 Paroxysmal atrial tachycardia.

Contraindicatio  Hypersensitivity;
n  Uncontrolled ventricular arrhythmias;
 AV block (in absence of pacemaker);
 Idiopathic hypertrophic subaortic stenosis;
 Constrictive pericarditis;
 Known alcohol intolerance (elixir only).

Side Effects  Dizziness.

 Changes in mood and mental alertness, including confusion,
depression and lost interest in usual activities.
 Anxiety.
 Nausea, vomiting and diarrhea.
 Headache.
 Rash.
 Growth or enlargement of breast tissue in men
(gynecomastia)
 Weakness.
Adverse Effects  CNS: fatigue, headache, weakness.
 CV: ARRHYTHMIAS, bradycardia, ECG changes, AV block,
SA block
 EENT: blurred vision, yellow or green vision
 GI: anorexia, nausea, vomiting, diarrhea
 Hemat: thrombocytopenia
 Metabolic: electrolyte imbalances with acute digoxin toxicity

Drug  Thiazide and loop diuretics, piperacillin/tazobactam,

Interactions amphotericin B, corticosteroids, and excessive use of
laxatives may cause hypokalemia which may ↑ risk of
toxicity.
 Quinidine and ritonavir may ↑ levels and lead to toxicity; ↓
digoxin dose by 30–50%.
 Amiodarone may ↑ levels and lead to toxicity; ↓ digoxin dose
by 50%.
 Cyclosporine, itraconazole, mirabegron, propafenone,
quinine, spironolactone, and verapamil may ↑ levels and
lead to toxicity; serum level monitoring/dose ↓ may be
required.
 Levels may be ↓ by some antineoplastics (bleomycin,
carmustine, cyclophosphamide, cytarabine, doxorubicin,
methotrexate, procarbazine, vincristine ), activated charcoal,
cholestyramine, colestipol, metoclopramide, penicillamine,
rifampin, or sulfasalazine .
 In a small percentage (10%) of patients gut bacteria
metabolize digoxin to inactive compounds macrolide anti-
infectives (erythromycin, azithromycin, clarithromycin ) and
tetracyclines , by killing these bacteria, will cause ↑ levels
and toxicity; dose may need to be ↓ for up to 9 wk.
 Additive bradycardia may occur with beta blockers, diltiazem,
verapamil, clonidine, ivabradine, and other antiarrhythmics
(quinidine, disopyramide ).
  Concurrent use of sympathomimetics may ↑ risk of
arrhythmias.
 Thyroid hormones may ↓ therapeutic effects.

Nursing 1. Monitor apical pulse for 1 full min before administering.

Interventions Withhold dose and notify health care professional if pulse
rate is <60 bpm in an adult, <70 bpm in a child, or <90 bpm in
an infant. Notify health care professional promptly of any
significant changes in rate, rhythm, or quality of pulse.
2. Pedi: Heart rate varies in children depending on age, ask
health care professional to specify at what heart rates digoxin
should be withheld.
3. Monitor BP periodically in patients receiving IV digoxin.
4. Monitor ECG during IV administration and 6 hr after each
dose. Notify health care professional if bradycardia or new
arrhythmias occur.
5. Observe IV site for redness or infiltration; extravasation can
lead to tissue irritation and sloughing.
6. Monitor intake and output ratios and daily weights. Assess for
peripheral edema, and auscultate lungs for rales/crackles
throughout therapy.
7. Before administering initial loading dose, determine whether
patient has taken any digoxin in the preceding 2–3 wk.
8. Instruct patient to take medication as directed, at same time
each day. Teach parents or caregivers of infants and children
how to accurately measure medication. Take missed doses
within 12 hr of scheduled dose or omit. Do not double doses.
Consult health care professional if doses for 2 or more days
are missed. Do not discontinue medication without consulting
health care professional.
9. Teach patient to take pulse and to contact health care
professional before taking medication if pulse rate is <60 or
>100.
10. Pedi: Teach parents or caregivers that changes in heart rate,
 especially bradycardia, are among the first signs of digoxin
toxicity in infants and children. Instruct parents or caregivers
in apical heart rate assessment and ask them to notify health
care professional if heart rate is outside of range set by
health care professional before administering the next
scheduled dose.
11. Instruct patient to keep digoxin tablets in their original
container and not to mix in pill boxes with other medications;
may look similar to and may be mistaken for other
medications.
12. Advise patient that sharing of this medication can be
dangerous.
13. Advise patient to notify health care professional of this
medication regimen before treatment.
14. Patients taking digoxin should carry identification describing
disease process and medication regimen at all times.

REFERENCES:

Sanoski, C. (2018). Digoxin (Lanoxin): Davis's Drug Guide. Retrieved April 19, 2020, from
https://www.drugguide.com/ddo/view/Davis-Drug-Guide/51218/all/digoxin?q=digoxin

Vallerand, A. (2017). Furosemide (Lasix): Davis's Drug Guide. Retrieved April 19, 2020,
from https://www.drugguide.com/ddo/view/Davis-Drug-Guide/51345/all/furosemide