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Diuretic dosing in edema

Drug dosing reference for commonly used diuretic medications in pediatric patients, specifically for the treatment of edema.

Other indications may have different typical doses/ranges. This page does not include dose adjustments for kidney/hepatic impairment.

  • pill
  • liquid
  • compounded liquid
  • injection (IV)
  • continuous infusion (drip/gtt)
  • intramuscular (IM)

Loop diuretics

tip

Enteral equivalents: furosemide 40 mg = bumetanide 1 mg = ethacrynic acid 50 mg = torsemide 20 mg

Furosemide (Lasix®)

[UpToDate] [LPCH Lexicomp]
Dose conversion: bioavailability is variable (10-100%); generally assume 2:1 potency for IV:enteral, but may want to be more cautious (1.5:1 or 1:1) depending on clinical scenario

Enteral

  • Onset of diuresis 30-60 min, with peak in 1-2 hours and duration of 6-8 hours
    • Preemies: 1-2 mg/kg q12-24h
      • Max 2 mg/kg/day in ≤31 weeks adjusted (↑ risk of ototoxicity)
    • Neonates: 1-2 mg/kg q6-8h
    • Children: 1-2 mg/kg q6-24h
      • Max 6 mg/kg/dose (≤200 mg/dose, ≤10 mg/kg/day)
    • Adults: 20-80 mg/dose q6-8h
      • Titrate by 20-40 mg q6-8h
      • Max 200 mg/dose (≤600 mg/day)

Intravenous (IV)

warning

To limit risk of ototoxicity, limit the infusion rate to a max of 0.5 mg/kg/min (4 mg/min) in children. In adults, limit infusion rate to 20-40 mg/minute for routine doses, but for high doses (≥160 mg) the rate should be limited to 4 mg/min.

  • Onset of diuresis ≤5 min, with peak in first 30 min and duration of ~2 hours
  • Intermittent
    • Can also be given IM (dosed 1:1)
    • Preemies: 0.5-1 mg/kg/dose q12-24h
      • Max 1 mg/kg/day in ≤31 weeks adjusted (↑ risk of ototoxicity)
    • Neonates: 0.5-1 mg/kg/dose q6-8h
    • Children: 0.5-1 mg/kg/dose q6-24h
      • Usual range 0.5-2 mg/kg/dose, rarely will use 3 mg/kg/dose for renal impairment (e.g., "diuretic challenge")
      • Max 6 mg/kg/dose (200 mg/dose, 10 mg/kg/day)
    • Adults: 20-80 mg/dose q6-12h
      • Titrate by 20 mg/dose q1-2h until desired effect seen
      • Max 200 mg/dose (≤600 mg/day)
  • Continuous
    • Children: 0.05-0.4 mg/kg/h
      • May load with 0.1 mg/kg IV bolus
    • Adults: 10-40 mg/h
      • May load with 20-40 mg IV bolus

Bumetanide (Bumex®)

[UpToDate] [LPCH Lexicomp]
Dose conversion: good bioavailability (>80%); assume 1:1 potency IV:PO

Enteral

  • Onset of diuresis 30-60 min, with peak in 1-2 hours and duration of 4-6 hours
  • Neonates: 0.01-0.05 mg/kg q12-48h
  • Infants/Children: 0.01-0.1 mg/kg q6-24h
    • Max 10 mg/day; study of infants (0-6 mo) showed no improvement in diuretic effect above 0.04 mg/kg/dose
  • Adults: 0.5-1 mg q8-24h
    • Max 10 mg/day

Intravenous (IV)

  • Onset of diuresis within minutes, with peak in first 30 min
  • Intermittent
    • Neonates: 0.01-0.05 mg/kg q12-48h
    • Infants/Children: 0.01-0.1 mg/kg/dose q6-24h
      • Max 10 mg/day; study of infants (0-6 mo) showed no improvement in diuretic effect above 0.04 mg/kg/dose
    • Adults: 0.5-1 mg q8-24h
      • Max 10 mg/day
  • Continuous
    • Infants/Children: 5 mcg/kg/h
      • Titrate by 5 mcg/kg/h
      • Usual range 5-15 mcg/kg/h
      • Max 30 mcg/kg/h
    • Adults: 0.5-2 mg/h
      • May load with 1 mg IV bolus
      • Max 5 mg/h

Ethacrynic acid (Edecrin®)

[UpToDate] [LPCH Lexicomp]

warning

Has greater ototoxicity compared to other loop diuretics. Reserve for patients with sensitivity to sulfonamide-based loop diuretics (furosemide, bumetanide, torsemide) who are refractory to other diuretics.

Enteral

  • Start with daily dosing; later, may dose daily or divide BID (or even TID in children)
  • Children: 1 mg/kg q24h
    • Titrate q48-72h
    • Max 3 mg/kg/day (400 mg/day)
  • Adults: 25-50 mg q24h
    • Titrate q24h
    • Usual range 50-200 mg
    • Max 400 mg/day

Intravenous (IV)

danger

Risk of thrombophlebitis; limit IV injections to single doses if possible and rotate IV access if additional doses are necessary

  • Intermittent:icon{name="healthicons:syringe-outline" class="ml-1.5 w-5 h-5"}
    • Children: 0.5-1 mg/kg/dose q8-24h
      • Max 50 mg/dose
    • Adult: 50 mg or 0.5-1 mg/kg x1 dose
      • Max 100 mg x1 dose (if necessary, may do 1 additional dose 8-12 hours later)
  • Continuous
    • Children:
      • 0.1 mg/kg/h
      • Usual range 0.1-0.35 mg/kg/h
      • Max 0.5 mg/kg/h

Thiazide and thiazide-like

tip

Enteral equivalents: hydrochlorothiazide 25 mg = metolazone 2 mg = chlorthalidone 12.5 mg

Chlorothiazide (Diuril®)

[UpToDate] [LPCH Lexicomp]

Enteral

  • Children:
    • 5-10 mg/kg q6-12h
    • Max 40 mg/kg/day (2000 mg/day)
  • Adults:
    • 500-2000 mg q12-24h
    • Max 2000 mg/day

Intravenous (IV)

warning

Avoid extravasation, extremely irritating to tissues.

  • Children:
    • 2.5-10 mg/kg q6-12h
    • Typical 5-10 mg/kg q6-8h
    • Max 40 mg/kg/day (2000 mg/day)
  • Adults:
    • 500 mg q6-24h
    • Max 2000 mg/day

Hydrochlorothiazide (HCTZ)

[UpToDate] [LPCH Lexicomp]

Enteral

  • May dose daily or divide BID
  • Age <6 months: 1-3 mg/kg/day
    • Max 37.5 mg/day
  • Age ≥6 months to <2 years: 1-2 mg/kg/day
    • Max 37.5 mg/day
  • Age ≥2 to <12 years: 1-2 mg/kg/day
    • Max 100 mg/day
  • Age ≥12 years: 1-2 mg/kg/day
    • Max 200 mg/day
  • Adults: 25-100 mg/day
    • Max 200 mg/day

Metolazone (Zaroxolyn®)

[UpToDate] [LPCH Lexicomp]

Enteral

  • May dose daily or divide BID
  • Infants/Children: 0.2-0.4 mg/kg/day
    • Lower doses (0.05-1 mg/kg q24h) may be effective
    • Max 20 mg/day
  • Adults:
    • 2.5-5 mg/day
    • Max 20 mg/day

Chlorthalidone (Hygroton®, Thalitone®)

[UpToDate] [LPCH Lexicomp]

Enteral

  • Children: 0.3 mg/kg daily
    • Usual range ≤25 mg/day; >25 mg → ↑ risk of side effects without much improvement in diuretic effect
    • Max 2 mg/kg/day (50 mg/day)
  • Adults: 12.5-25 mg daily (or daily PRN)
    • Max 200 mg/day

Potassium-sparing diuretics

tip

Enteral equivalents: spironolactone 12.5 mg = amiloride 5 mg = eplerenone 25 mg

Spironolactone (Aldactone®, CaroSpir®)

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Enteral

warning

Liquid formulation (CaroSpir®) is not equivalent to tablet (15-37% higher serum concentration vs tablet); decrease doses by ~20% when using the liquid formulation

  • Sometimes packaged with HCTZ (Aldactazide®)
  • Neonates: 1-3 mg/kg/day
    • May dose daily or divide BID
  • Infants/Children: 1-3.3 mg/kg/day
    • May dose daily or divide BID/up to q6h
    • Max 100 mg/day
  • Adults: 12.5-25 mg q24h
    • Titrate every 2-4 weeks (weekly if severe asymptomatic hypertension)
    • Usual range 25-50 mg
    • Max 100 mg/day

Amiloride (Midamor®)

[UpToDate] [LPCH Lexicomp]

Enteral

  • May dose daily or divide BID
  • Children:
    • 0.3-0.625 mg/day (≤5 mg/day)
    • Titrate by ≤5 mg/day
    • Max 20 mg/day
  • Adults:
    • 5 mg/day
    • Titrate by ≤5 mg/day
    • Max 20 mg/day