FRUSOL Oral solution Ref.[27733] Active ingredients: Furosemide

Conditions requiring correction before furosemide is started (see also section 4.3):

• Hypotension
• Hypovolaemia
• Severe electrolyte disturbances – particularly hypokalaemia, hyponatraemia and acid-base disturbances

Furosemide is not recommended:

• In patients at high risk for radiocontrast nephropathy – it should not be used for diuresis as part of the preventative measures against radiocontrast-induced nephropathy.
• In elderly patients with dementia taking risperidone – Increased mortality (see below and section 4.5)

Particular caution and/or dose reduction required:

• elderly patients (lower initial dose as particularly susceptible to side-effects – see section 4.2).
• difficulty with micturition including prostatic hypertrophy (increased risk of urinary retention: consider lower dose). Closely monitor patients with partial occlusion of the urinary tract
• in moderate liver congestion dosage adjustment may be needed
• diabetes mellitus (latent diabetes may become overt: insulin requirements in established diabetes may increase: stop furosemide before a glucose tolerance test)
• pregnancy (see section 4.6)
• gout (furosemide may raise uric acid levels/precipitate gout)impaired hepatic function – hepatic failure and alcoholic cirrhosis particularly predispose to hypokalaemia and hypomagnesaemia (see section 4.3 and below – monitoring required)
• impaired renal function and hepato-renal syndrome (see section 4.3 and below – monitoring required)
• adrenal disease (see section 4.3 – contraindication in Addison’s disease)
• hypoproteinemia e.g. nephrotic syndrome (effect of furosemide may be impaired and its ototoxicity potentiated – cautious dose titration required).
• acute hypercalcaemia (dehydration results from vomiting and diuresis – correct before giving furosemide). Treatment of hypercalcaemia with a high dose of furosemide results in fluid and electrolyte depletion – meticulous fluid replacement and correction of electrolyte required
• premature infants – possible development of nephrocalcinosis/ nephrolithiasis (see below – monitoring of renal function required)
• some diuretics have been considered unsafe in acute porphyria
• symptomatic hypotension leading to dizziness, fainting or loss of consciousness can occur in patients treated with furosemide, particularly in the elderly, patients on other medications which can cause hypotension and patients with other medical conditions that are risks for hypotension.

Avoidance with other medicines (see also section 4.5 for other interactions):

• concurrent NSAIDs should be avoided – if not possible diuretic effect of furosemide may be attenuated
• ACE-inhibitors & Angiotensin II receptor antagonists – severe hypotension may occur – dose of furosemide should be reduced/stopped (3 days) before starting or increasing the dose of these
• concurrent risperidone in elderly patients with dementia has resulted in increased mortality – no mechanism for and no consistent pattern of deaths identified (see section 4.5)

Laboratory and other monitoring requirements:

• Serum sodium

Particularly in the elderly or in patients liable to electrolyte deficiency

• Serum potassium

The possibility of hypokalaemia should be taken into account, in particular in patients with cirrhosis of the liver, those receiving concomitant treatment with corticosteroids, those with an unbalanced diet and those who abuse laxatives. Regular monitoring of the potassium, and if necessary treatment with a potassium supplement, is recommended in all cases, but is essential at higher doses and in patients with impaired renal function. It is especially important in the event of concomitant treatment with digoxin, as potassium deficiency can trigger or exacerbate the symptoms of digitalis intoxication (see section 4.5). A potassium-rich diet is recommended during long-term use.

Frequent checks of the serum potassium are necessary in patients with impaired renal function and creatinine clearance below 60ml/min per 1.73m² body surface area as well as in cases where furosemide is taken in combination with certain other drugs which may lead to an increase in potassium levels (see section 4.5 & refer to section 4.8 for details of electrolyte and metabolic abnormalities)

• Renal function

Frequent BUN in first few months of treatment, periodically thereafter. Long-term/high-dose BUN should regularly be measured. Marked diuresis can cause reversible impairment of kidney function in patients with renal dysfunction. Adequate fluid intake is necessary in such patients. Serum creatinine and urea levels tend to rise during treatment. If used in premature infants there is a risk of nephrocalcinosis/nephrolithiasis so renal function must be monitored and renal ultrasonography performed.

• Glucose

Adverse effect on carbohydrate metabolism – exacerbation of existing carbohydrate intolerance or diabetes mellitus. Regular monitoring of blood glucose levels is desirable.

• Other electrolytes

Patients with hepatic failure/alcoholic cirrhosis are particularly at risk of hypomagnesemia (as well as hypokalaemia). During long-term therapy (especially at high doses) magnesium, calcium, chloride, bicarbonate and uric acid should be regularly measured.

Clinical monitoring requirements (see also section 4.8):

Regular monitoring for:

• blood dyscrasias. If these occur, stop furosemide immediately
• liver damage
• idiosyncratic reactions

Excipient Warnings:

This product contains:

• Ethanol (Alcohol) – This medicine contains 79.5 mg of alcohol (ethanol) in each ml. The amount in 5ml of this medicine is equivalent to less than 10 ml beer or 4 ml wine. The amount of alcohol in this medicine is not likely to have an effect in adults and adolescents, and its effects in children are not likely to be noticeable. It may have some effects in younger children, for example feeling sleepy. The alcohol in this medicine may alter the effects of other medicines. Talk to your doctor or pharmacist if you are taking other medicines. If you are pregnant or breast-feeding, talk to your doctor or pharmacist before taking this medicine. If you are addicted to alcohol, talk to your doctor or pharmacist before taking this medicine.
• Liquid Maltitol (E 965) – Patients with rare hereditary problem of fructose intolerance should not take this medicine. May have a mild laxative effect.
• Quinoline Yellow (E104) – Can cause allergic-type reactions including asthma. The allergy is more common in people who are allergic to aspirin.
• Propylene Glycol (E1520) - This medicine contains 0.35 mg propylene glycol in each 5ml. If your baby is less than 4 weeks old, talk to your doctor or pharmacist before giving them this medicine, in particular if the baby is given other medicines that contain propylene glycol or alcohol.
• This medicine contains less than 1 mmol sodium (23 mg) per 5ml, that is to say essentially ‘sodium-free’.

Antihypertensives: enhanced hypotensive effect possible with all types. Concurrent use with ACE inhibitors or Angiotensin II receptor antagonists can result in marked falls in blood pressure, furosemide should be stopped or the dose reduced before starting an ACE-inhibitor or Angiotensin II receptor antagonists (see section 4.4). Increased risk of first dose hypotension with post-synaptic alpha-blockers (eg prazosin). Furosemide may interact with ACE inhibitors causing impaired renal function.

Antipsychotics: furosemide-induced hypokalaemia increases the risk of cardiac toxicity. Avoid concurrent use with pimozide. Increased risk of ventricular arrhythmias with pimozide (avoid concurrent use), amisulpride or sertindole. Enhanced hypotensive effect with phenothiazines.

In placebo-controlled trials in elderly patients with dementia, a higher incidence of mortality was observed in patients treated with furosemide plus risperidone. No consistent pattern for cause of death was observed but caution should be exercised and the risks and benefits of this combination considered prior to the decision to use.

Anti-arrhythmics (including amiodarone, disopyramide, flecainide and sotalol): risk of cardiac toxicity (because of furosemide-induced hypokalaemia). The effects of lidocaine, tocainide or mexiletine may be antagonised by furosemide.

Cardiac glycosides: hypokalaemia and electrolyte disturbances (including hypomagnesemia) increase the risk of cardiac toxicity.

Drugs that prolong Q-T interval: increased risk of toxicity with furosemide induced electrolyte disturbances.

Vasodilators: enhanced hypotensive effect with moxisylyte (thymoxamine) or hydralazine.

Other diuretics: profound diuresis possible when furosemide given with metolazone. Increased risk of hypokalaemia with thiazides. Contraindicated with potassium sparing diuretics (eg amiloride spironolactone) - increased risk of hyperkalaemia (see section 4.3). Concurrent use with tetracyclines may increase the risk of rising BUN (see section 4.4 – monitoring).

Renin inhibitors: aliskiren reduces plasma concentrations of furosemide.

Nitrates: enhanced hypotensive effect.

Lithium: furosemide reduces lithium excretion with increased plasma lithium concentrations (risk of cardio- and/or neuro-toxicity). Avoid concomitant administration unless plasma levels are monitored.

Chelating agents: sucralfate may decrease the gastro-intestinal absorption of furosemide – the 2 drugs should be taken at least 2 hours apart.

Lipid regulating drugs: Bile acid sequestrants (eg colestyramine: colestipol) – reduced absorption of furosemide – administer 2 to 3 hours apart.

NSAIDs: increased risk of nephrotoxicity (especially with pre-existing hypovolaemia/dehydration. Indometacin and ketorolac may antagonise the effects of furosemide (avoid if possible see section 4.4). In patients with dehydration or hypovolaemia, NSAIDs may cause acute renal insufficiency.

Salicylates: effects may be potentiated by furosemide. Salicylic toxicity may be increased by furosemide.

Antibiotics: increased risk of ototoxicity with aminoglycosides, polymixins or vancomycin – only use concurrently if compelling reasons. Increased risk of nephrotoxicity with aminoglycosides or cefaloridine. Furosemide can decrease vancomycin serum levels after cardiac surgery. Increased risk of hyponatraemia with trimethoprim.

Antiviral: plasma concentrations of diuretics may be increased by nelfinavir, ritonavir or saquinavir.

Antidepressants: enhanced hypotensive effect with MAOIs. Increased risk of postural hypotension with TCAs (tricyclic antidepressants). Increased risk of hypokalaemia with reboxetine.

Antidiabetics: hypoglycaemic effects antagonised by furosemide.

Antiepileptics: increased risk of hyponatraemia with carbamazepine. Diuretic effect reduced by phenytoin.

Antihistamines: hypokalaemia with increased risk of cardiac toxicity.

Antifungals: increased risk of hypokalaemia and nephrotoxicity with amphotericin.

Anxiolytics and hypnotics: enhanced hypotensive effect. Chloral hydrate or triclofos may displace thyroid hormone from binding site.

CNS stimulants (drugs used for ADHD): hypokalaemia increases the risk of ventricular arrhythmias.

Corticosteroids: diuretic effect anatgonised (sodium retention) and increased risk of hypokalaemia.

Cytotoxics: increased risk of nephrotoxicity and ototoxicity with platinum compounds/cisplatin.

Anti-metabolites: effects of furosemide may be reduced by methotrexate and furosemide may reduce renal clearance of methotrexate.

Potassium salts: contraindicated – increased risk of hyperkalaemia (see section 4.3).

Dopaminergics: enhanced hypotensive effect with levodopa.

Immunomodulators: enhanced hypotensive effect with aldesleukin. Increased risk of hyperkalaemia with ciclosprin and tacrolimus. Increased risk of gouty arthritis with ciclosporin.

Muscle relaxants: enhanced hypotensive effect with baclofen or tizanidine. Increased effect of curare-like muscle relaxants.

Oestrogens: diuretic effect antagonised.

Progestogens (drospirenone): increased risk of hyperkalaemia and diuretic effect antagonised.

Prostaglandins: enhanced hypotensive effect with alprostadil.

Sympathomimetics: increased risk of hypokalaemia with high doses of beta2 sympathomimetics.

Theophylline: enhanced hypotensive effect.

Probenecid: effects of furosemide may be reduced by probenecid and furosemide may reduce renal clearance of probenecid.

Anaesthetic agents: general anaesthetic agents may enhance the hypotensive effects of furosemide. The effects of curare may be enhanced by furosemide.

Warfarin and clofibrate: compete with furosemide in binding to serum albumin – possibly significant if this is low (eg nephrotic syndrome).

Aminoglutethimide: concomitant use may increase the risk of hyponatraemia.

Alcohol: enhanced hypotensive effect.

Laxative abuse: increases the risk of potassium loss.

Liquorice: excess intake may increase the risk of hypokalaemia.

Pregnancy

Frusol must not be given during pregnancy unless there are compelling medical reasons.

Breast-feeding

Furosemide may inhibit lactation and may pass into breast milk. Women must not breastfeed if they are treated with furosemide.

Mental alertness may be reduced and the ability to drive or operate machinery may be impaired.

Very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000); Frequency not known (cannot be estimated from the available data).

Blood and lymphatic system disorders

Uncommon: aplastic anaemia

Rare: bone marrow depression (necessitates withdrawal of treatment), eosinophilia, leucopenia.

Very rare: haemolytic anaemia, agranulocytosis, thrombocytopenia

Metabolism and nutritional disorders

Very common: dehydration, hyponatraemia, hypochloremic metabolic alkalosis, hypocalcaemia, hypomagnesemia (incidences of the last three are reduced by triamterene)

Common: Hypovolaemia, hypochloraemia

Uncommon: impaired glucose tolerance (by hypokalaemia) hyperuricaemia, gout, reduction of serum HDL-cholesterol, elevation of serum LDL-cholesterol, elevation of serum triglycerides, hyperglycaemia.

Very rare: tetany

Frequency not known: aggravated pre-existing metabolic alkalosis (in decompensated cirrhosis of the liver), fluid and electrolyte disturbances, excretion of potassium increased* In patients with diabetes mellitus this may lead to deterioration of metabolic control; latent diabetes mellitus may become manifest

Psychiatric disorder

Rare: psychiatric disorder NOC

Nervous system disorders

Rare: paraesthesia, confusion, headache

Not known: dizziness, fainting and loss of consciousness (caused by symptomatic hypotension)

Eye disorders

Uncommon: visual disturbance, blurred vision, yellow vision.

Ear and labyrinth disorders

Uncommon: deafness (sometimes irreversible)

Rare: tinnitus and reversible or irreversible loss of hearing (although usually transitory, particularly in patients with renal failure, hypoproteinaemia (e.g. in nephritic syndrome)

Cardiac disorders

Uncommon: orthostatic intolerance, cardiac arrhythmias, increased risk or persistence of patent ductus arteriosus in premature infants.

Vascular disorders

Very common: hypotension, (which, if pronounced may cause signs and symptoms such as impairment of concentration and reactions, light-headedness, sensations of pressure in the head, headache, drowsiness, weakness, disorders of vision, dry mouth, orthostatic intolerance).

Rare: vasculitis, thrombosis, shock

Gastrointestinal disorders

Uncommon: dry mouth, thirst, nausea, bowel motility disturbances, vomiting, diarrhoea, constipation

Rare: acute pancreatitis (in long-term diuretic treatment, including furosemide).

Hepatobiliary disorders

Rare: pure intrahepatic cholestasis (jaundice), hepatic function abnormal.

Skin and subcutaneous tissue disorders

Rare: rash, pruritus, photosensitivity, toxic epidermal necrolysis.

Frequency not known:

urticaria, erythema multiforme, purpura, exfoliative dermatitis, itching, allergic reactions, such as skin rashes, various forms of dermatitis including urticaria, bullous lesions, acute generalised exanthematous pustulosis (AGEP). When these occur treatment should be withdrawn. Steven-Johnson’s syndrome

Musculoskeletal and connective tissue disorders

Uncommon: muscle cramps, muscle weakness.

Renal and urinary disorders

Very common: nephrocalcinosis in infants

Uncommon: reduced diuresis, urinary incontinence, urinary obstruction (in patients with hyperplasia of the prostate, bladder inability to empty, urethral stricture unspecified).

Rare: acute renal failure.

Frequency not known: Hepatic encephalopathy in patients with hepatocellular insufficiency may occur.

Congenital, familial and genetic disorders

Rare: patent ductus arteriosus

General disorders and administration site conditions

Uncommon: Fatigue

Rare: malaise, fever, severe anaphylactoid or anaphylactic reactions (e.g. with shock).

Investigations

Common: creatinine increased, blood urea increased

Rare: Transaminases increased, blood

^* Potassium deficiency manifests itself in neuromuscular symptoms (muscular weakness, paralysis), intestinal symptoms (vomiting, constipation, meterorism), renal symptoms (polyuria) or cardiac symptoms. Severe potassium depletion can result in paralytic ileus or confusion, which can result in coma.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at www.mhra.gov.uk/yellowcard.

None known.