Intended for healthcare professionals

Practice Uncertainties

How to prescribe loop diuretics in oedema

BMJ 2019; 364 doi: (Published 21 February 2019) Cite this as: BMJ 2019;364:l359
  1. Steven D Anisman, invasive cardiologist1,
  2. Stephen B Erickson, clinical nephrologist2,
  3. Nancy E Morden, primary care physician3
  1. 1SVMC Cardiology, Dartmouth Hitchcock Department of Cardiovascular Medicine, Bennington, VT, USA
  2. 2Mayo Clinic, Division of Nephrology and Hypertension, Rochester, MN, USA
  3. 3The Dartmouth Institute for Health Policy & Clinical Practice, The Department of Community and Family Medicine, The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
  1. Correspondence to S D Anisman steven.anisman{at}

What you need to know

  • Loop diuretics respond in an all-or-none fashion, meaning there is no way to gradually increase or decrease the diuretic effect of these medications; they are either “on” or “off.” For a given individual, a dose is either effective or not

  • Loop diuretics are widely used for symptoms of oedema of any aetiology

  • There is little guidance on which loop diuretic to choose, but moderate strength evidence suggests torsemide may have advantages over furosemide, including higher potency, longer duration of action, and possibly improved symptomatic improvement

  • As-needed dosing of loop diuretics may help patients control their volume status while minimising the risk of hypovolaemia and other side effects of loop diuretics

Loop diuretics are commonly prescribed to manage oedema symptoms such as swollen legs or breathlessness and to relieve fluid overload. They are widely recommended by guidelines and organisations such as the National Institute for Health and Care Excellence (NICE) in the UK. The loop diuretics available in the UK are furosemide, bumetanide, and torasemide. But which option is best?

The pharmacokinetics of loop diuretics are well characterised. Studies and trials on humans and animals describe pharmacodynamic differences between loop diuretics. However, there is limited evidence directly comparing them. In particular, there is little and low quality information comparing the clinical outcomes of furosemide with the less commonly chosen alternatives torsemide and bumetanide. This article (box 1) outlines some pharmacokinetic differences between available loop diuretics that may influence loop selection in practice and advises how to dose them effectively.

Box 1

How this article was created

We initially wrote this article in response to questions primary care clinicians frequently posed when seeking assistance in managing oedema in patients with heart failure. Evidence was gathered over a 15 year period in response to patient and physician queries regarding the management of oedema and the use of loop diuretics. We …

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