Oedema
Initially 40mg daily then adjusted according to response.
Initially 40mg daily then adjusted according to response.
Slow intravenous injection, initially 20-50mg. Furosemide may be given by intravenous infusion at a rate not exceeding 4mg/minute.
Slow intravenous injection, initially 20-50mg. Furosemide may be given by intravenous infusion at a rate not exceeding 4mg/minute.
Slow intravenous injection, initially 20-50mg. Furosemide may be given by intravenous infusion at a rate not exceeding 4mg/minute.
In those not responding to furosemide.
Initially 1mg daily then adjusted according to response.
Initially 1mg daily then adjusted according to response.
For patients with resistant oedema. A new licensed metolazone preparation Xaqua is available that is not interchangeable with other metolazone preparations. See prescribing notes.
Dose as per specialist.
Prescribing Notes:
- Furosemide produces a dose-dependent diuresis within 1 hour if given orally or 30 minutes if given intravenously; duration of action, 6 hours.
- Bumetanide 1mg is equivalent to 40mg furosemide.
- Xaqua tablets are not interchangeable with other metolazone preparations prescribe by brand name. Patients previously on other metolazone formulations (unlicensed medicines) are recommended to be switched to Xaqua under specialist supervision due to potential differences in bioavailability, follow local board guidance. Arrangements for clinical monitoring and dose adjustment should be made on an individual patient basis after an assessment of the individual clinical risk. Relevant parameters for monitoring include blood urea, electrolytes and creatinine, blood pressure and weight. The frequency of monitoring should be based on the individual patient.
- Combination products containing a diuretic plus potassium do not contain sufficient potassium to correct hypokalaemia and therefore are not recommended for correction of hypokalaemia.
- Fixed combinations of diuretics should only be considered if adherence is a problem.
- All diuretics have the propensity to cause postural hypotension and thus collapse and falls in older patients.
History Notes
09/10/2023
Metolazone formulations updated, ERWG March 2023.
28/11/2022
Information added to highlight differences in bioavailability between metolazone formulations, ERFC Sept 22.
16/02/2022
East Region Formulary content agreed.
To be initiated under advice from paediatric nephrologist – most causes of oedema in children will be renal (e.g. nephrotic, CKD), rarely cardiac, rarely liver failure/low albumin.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
Prescribing Notes:
- Furosemide produces a dose-dependent diuresis within 1 hour if given orally or 30 minutes if given intravenously; duration of action, 6 to 8 hours. Half-life is very variable in the neonatal period and may be up to 24hours in preterm infants.
- In an intensive care setting, continuous infusion of furosemide may be given.
- In children no longer in nappies, time doses to minimize social disruption.
- Amiloride and spironolactone are weak diuretics with potassium-sparing properties, given with other diuretics if hypokalaemia is a problem; may take 2-3 days for full effect.
- Spironolactone is an aldosterone antagonist used for oedema in hepatic cirrhosis or heart failure, and primary hyperaldosteronism.
- Potassium-sparing diuretics should be used with caution in renal impairment.
- Children receiving spironolactone will need to have their potassium levels checked, particularly if also on an ACE inhibitor.
- Potassium sparing diuretics are usually prescribed short-term for patients with left to right cardiac shunts prior to surgical correction or in the post-operative period (for up to 6 weeks). They may be given long-term in patients with poor myocardial function.
- When oedema is seen in acute severe illness in paediatrics it is important to find the cause rather than to treat with diuretics.
- Metolazone may be considered for resistant oedema (e.g. nephrotic syndrome, congestive heart failure) and hypertension associated with this. It is used in conjunction with a loop diuretic such as furosemide. It is traditionally given 30-60 minutes before furosemide to achieve a maximal synergistic effect.
History Notes
19/06/2023
East Region Formulary content agreed - ERFC 07/06/2023.