Loop diuretic doses for adult patients with common causes of edema

	Starting dose (oral or intravenous*)			Maximum effective dose^¶ (higher individual doses or more frequent dosing intervals are unlikely to produce substantial additional diuresis)^Δ			Maximal recommended daily dose^¶ (greater daily total doses are associated with a risk for toxicity)
	Furosemide	Bumetanide	Torsemide	Furosemide	Bumetanide	Torsemide	Furosemide	Bumetanide	Torsemide
Heart failure^◊	20 mg once or twice daily	0.5 mg once or twice daily	5 mg once daily	80 mg 3 times daily	3 mg 3 times daily	50 mg twice daily	600 mg	10 mg	200 mg
Cirrhotic ascites^§	40 mg once or twice daily	1 mg once or twice daily	10 mg once daily	40 mg 3 times daily	1 mg 3 times daily	20 mg twice daily	160 mg	4 mg	40 mg
Nephrotic syndrome	40 mg once or twice daily	1 mg once or twice daily	10 mg once daily	120 mg 3 times daily	3 mg 3 times daily	50 mg twice daily	600 mg	10 mg	200 mg
Chronic kidney disease^¥	‡	‡	‡	200 mg 3 times daily	10 mg 3 times daily	100 mg twice daily	600 mg	10 mg	200 mg
Acute kidney injury	80 mg once or twice daily	2 mg once or twice daily	20 mg once daily	500^† mg once	Not reported	Not reported	600 mg	Not reported	Not reported

* Refer to UpToDate topics on the maximum effective dose and major side effects of loop diuretics for details.
¶ Dose is delivered intravenously.
Δ More aggressive regimens have been shown to be safe and effective for acute decompensated heart failure. Refer to UpToDate topics on the use of diuretics in patients with heart failure for details.
◊ Guidelines from American College of Cardiology/American Heart Association^[1] recommend furosemide and bumetanide starting daily or twice daily and torsemide starting daily. Similar guidelines are available from the European Society of Cardiology^[2]. Note that higher doses may be useful in acute decompensated heart failure.
§ In most patients with cirrhosis, furosemide (or equivalent) should be combined with spironolactone at a ratio of 40 mg furosemide to 100 mg of spironolactone; the dosing ratio should be adjusted based upon the plasma potassium concentration. Refer to UpToDate topics on initial therapy of ascites for details.
¥ Chronic kidney disease alone typically does not cause edema but complicates the treatment of other edematous syndromes. In this situation, the presence of chronic kidney disease should guide dosing. Refer to UpToDate topics on the maximum effective dose and major side effects of loop diuretics for details.
‡ Initial diuretic doses for patients with chronic kidney disease depend on its stage but are generally higher than those given for patients with heart failure or cirrhosis.
† High doses of furosemide (500 mg) may be effective, but most authorities now avoid such high doses and, instead, recommend a single trial with a lower starting dose.

References:

Writing Committee Members, Yancy CW, Jessup M, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2013; 128:e240.
Mullens W, Damman K, Harjola VP, et al. The use of diuretics in heart failure with congestion - a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2019; 21:137.

Courtesy of David H Ellison, MD, FASN, FAHA.

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Loop diuretic doses for adult patients with common causes of edema