The pharmacology and therapeutics of diuretics in the pediatric patient

Hypochloremia Secondary to Diuretics in Preterm Infants: Should Clinicians Pay Close Attention?

Diuretic therapy, commonly used in the newborn intensive care unit, is associated with a variety of electrolyte abnormalities such as hyponatremia, hypokalemia, and hypochloremia. Hypochloremia, often ignored, is associated with significant morbidities and increased mortality in infants and adults. Clinicians respond in a reflex manner to hyponatremia than to hypochloremia. Hypochloremia is associated with nephrocalcinosis, hypochloremic alkalosis, and poor growth. Besides, the diuretic resistance associated with hypochloremia makes maintaining chloride levels in the physiological range even more logical. Since sodium supplementation counters the renal absorption of calcium and lack of evidence for spironolactone role in diuretic therapy for bronchopulmonary dysplasia (BPD), alternate chloride supplements such as potassium or arginine chloride may need to be considered in the management of hypochloremia due to diuretic therapy. In this review, we have summarized the current literature on hypochloremia secondary to diuretics and suggested a pragmatic approach to hypochloremia in preterm infants.

Clinical pharmacology of furosemide in neonates: a review

Furosemide is the diuretic most used in newborn infants. It blocks the Na⁺-K⁺-2Cl⁻ symporter in the thick ascending limb of the loop of Henle increasing urinary excretion of Na⁺ and Cl⁻. This article aimed to review the published data on the clinical pharmacology of furosemide in neonates to provide a critical, comprehensive, authoritative and, updated survey on the metabolism, pharmacokinetics, pharmacodynamics and side-effects of furosemide in neonates. The bibliographic search was performed using PubMed and EMBASE databases as search engines; January 2013 was the cutoff point. Furosemide half-life (t_1/2) is 6 to 20-fold longer, clearance (Cl) is 1.2 to 14-fold smaller and volume of distribution (Vd) is 1.3 to 6-fold larger than the adult values. t_1/2 shortens and Cl increases as the neonatal maturation proceeds. Continuous intravenous infusion of furosemide yields more controlled diuresis than the intermittent intravenous infusion. Furosemide may be administered by inhalation to infants with chronic lung disease to improve pulmonary mechanics. Furosemide stimulates prostaglandin E2 synthesis, a potent dilator of the patent ductus arteriosus, and the administration of furosemide to any preterm infants should be carefully weighed against the risk of precipitation of a symptomatic patent ductus arteriosus. Infants with low birthweight treated with chronic furosemide are at risk for the development of intra-renal calcifications.

Pediatric cardiovascular drug dosing in critically ill children and extracorporeal membrane oxygenation

Cardiovascular disease in children is common and results in significant morbidity and mortality. The sickest children with cardiovascular disease may require support with extracorporeal membrane oxygenation (ECMO), which provides life-saving assistance for children with refractory cardiorespiratory failure. Many classes of cardiovascular drugs are used in children, but very few of these agents have been well studied in children. The knowledge gap is even more pronounced in children supported by ECMO. Pharmacokinetic (PK) data collected to date (primarily from antibiotics and sedatives) suggest that the ECMO circuit has the potential to significantly alter the PK of drugs including changes in clearance and volume of distribution. Of all cardiovascular drugs administered to children supported by ECMO, only 11 have been partially studied and reported in the medical literature. Esmolol, amiodarone, nesiritide, bumetanide, sildenafil, and prostaglandin E1 seem to require dosing modifications in children supported by ECMO, whereas it seems that hydralazine, nicardipine, furosemide, epinephrine, and dopamine can be dosed similarly to children not supported by ECMO. However, trials evaluating the PK of these drugs in patients supported by ECMO are extremely limited (ie, case reports), and therefore, definitive dosing recommendations are not plausible. Research efforts should focus on evaluating the PK of drugs in patients on ECMO to avoid therapeutic failures or unnecessary toxicities.

Diuretics in pediatrics : current knowledge and future prospects

This review summarizes current knowledge on the pharmacology, pharmacokinetics, pharmacodynamics, and clinical application of the most commonly used diuretics in children. Diuretics are frequently prescribed drugs in children. Their main indication is to reduce fluid overload in acute and chronic disease states such as congestive heart failure and renal failure. As with most drugs used in children, optimal dosing schedules are largely unknown and empirical. This is undesirable as it can potentially result in either under- or over-treatment with the possibility of unwanted effects. The pharmacokinetics of diuretics vary in the different pediatric age groups as well as in different disease states. To exert their action, all diuretics, except spironolactone, have to reach the tubular lumen by glomerular filtration and/or proximal tubular secretion. Therefore, renal maturation and function influence drug delivery and consequently pharmacodynamics. Currently advised doses for diuretics are largely based on adult pharmacokinetic and pharmacodynamic studies. Therefore, additional pharmacokinetic and pharmacodynamic studies for the different pediatric age groups are necessary to develop dosing regimens based on pharmacokinetic and pharmacodynamic models for all routes of administration.

Bioequivalence evaluation of two brands of furosemide 40 mg tablets (Salurin and Lasix) in healthy human volunteers

A randomized, two-way, crossover, bioequivalence study was conducted in 24 fasting, healthy, male volunteers to compare two brands of furosemide 40 mg tablets, Salurin (Julphar, UAE) as test and Lasix (Hoechst AG, Germany) as reference product. The study was performed at the International Pharmaceutical Research Centre (IPRC), in a joint venture with Al-Mowasah Hospital, Amman, Jordan. One tablet of either formulation was administered with 240 ml of water after a 10 h overnight fast. After dosing, serial blood samples were collected for a period of 12 h. Plasma harvested from blood was analysed for furosemide by a validated HPLC method. Various pharmacokinetic parameters including AUC(0-t), AUC(0-infinity), C(max), T(max), T(1/2), and elimination rate constant were determined from plasma concentrations of both formulations. Statistical modules (ANOVA and 90% confidence intervals) were applied to AUC(0-t), AUC(0-infinity), and C(max) to assess the bioequivalence of the two brands which revealed no significant difference between them, and 90% CI fell within the US FDA accepted bioequivalence range of 80%-125%. Based on these statistical inferences, Salurin was found to be bioequivalent to Lasix.

Aminophylline in the treatment of fluid overload

OBJECTIVE

Aminophylline has not been studied as an adjunct diuretic in critically ill children. Our purpose was to evaluate its use in the treatment of fluid overload in these patients.

DESIGN

Open, controlled clinical trial.

SETTING

Pediatric intensive care unit.

PATIENTS

Study subjects ranged from 2-46 months of age, were fluid overloaded, and were receiving a continuous infusion of furosemide (> or =6 mg/kg/day). Patients with hemodynamic instability or liver dysfunction were excluded.

INTERVENTIONS

A single dose of aminophylline (6 mg/kg) was given after establishing baseline values. There were no additional diuretics or changes in vasoactive agents during the study.

MEASUREMENTS AND MAIN RESULTS

Urine output, creatinine clearance, and sodium and potassium excretion were measured before and after administration of the aminophylline bolus. Heart rate and mean arterial pressure (mm Hg) were recorded hourly. Urine output increased by >80% (p < .01) during the first 2 hrs after administration of the aminophylline bolus and then returned to baseline by 4 to 6 hrs. The change in urine output is consistent with the pharmacokinetics of aminophylline. Heart rate and mean arterial pressure exhibited a change of <10% from baseline.

CONCLUSIONS

These results suggest that aminophylline is an effective adjunct to furosemide in increasing diuresis in critically ill children with fluid overload. The increased diuresis can be accomplished without increased risk if drug levels are adequately monitored.

Pharmacokinetics and pharmacodynamics of bumetanide in critically ill pediatric patients

This prospective, open-label, clinical trial was conducted to describe the pharmacology of bumetanide in pediatric patients with edema. Nine infants, children, and young adults with edema who were selected for diuretic therapy were studied. After a brief baseline period, each patient received parenteral bumetanide 0.2 mg/kg divided into two equal doses and administered every 12 hours. Urine excretion rate, fractional and total excretion of Na+, Cl-, and K+, creatinine clearance, and plasma and urine concentrations of bumetanide were measured at multiple intervals after drug administration. Bumetanide caused significant increases in the excretion rate of urine and each measured electrolyte. Unexpectedly, creatinine clearance increased dramatically after each dose. Adverse effects, including hypokalemia and hypochloremic metabolic alkalosis, were evident by the end of the treatment period. The plasma pharmacokinetics of bumetanide revealed mean +/- standard deviation values for total clearance and apparent volume of distribution of 3.9 +/- 2.4 mL/min/kg and 0.74 +/- 0.54 L/kg, respectively. Patients excreted an average of 34% of each dose unchanged in the urine over 12 hours. Plasma concentrations of bumetanide accurately predicted several renal effects using a link model with similar pharmacodynamic parameters in each case. Parenteral bumetanide 0.1 mg/kg administered every 12 hours produced significant beneficial and adverse effects in these critically ill pediatric patients with edema. Pharmacokinetic parameters are similar to those previously reported for infants. Plasma concentrations of bumetanide can predict effect-compartment pharmacodynamics.

Neonatal diuretic therapy may not alter Children's preference for salt taste

Human neonates are occasionally treated with diuretics, and we investigated whether this causes a long-term enhancement of salt preference. Salt preference was examined in children aged 4-11 years. Twenty one of the children had received furosemide therapy as preterm neonates, and 24 were preterm neonates from the same ward that had no furosemide therapy. No differences were found between the two groups in preferred concentration of NaCl in soup, in consumption of salty items, and in blood and urine sodium and creatinine. However, in a tested subsample, fractional excretion of sodium (FENa) was higher in the neonatally treated children, suggesting increased salt intake. Reported severity of morning sickness in the mother when pregnant with the child, the child's history of diarrhoea and vomiting and degree of dietary salt exposure were obtained by questionnaire. These variables also did not influence salt preference, or blood and urine sodium and creatinine, except for a correlation between dietary salt exposure and blood sodium concentration. We conclude that while the physiological evidence suggests increased salt intake in children treated neonatally with furosemide, more sensitive tests of salt preference at this age are required to reveal any influence early mineralofluid loss may have on salt preference in childhood.

Analysis of the variability in the pharmacokinetics and pharmacodynamics of bumetanide in critically ill infants

OBJECTIVES

Account for the interindividual variability in the pharmacokinetics and pharmacodynamics of bumetanide after intravenous administration of single doses to critically ill infants.

METHODS

This prospective open-label study was carried out in the pediatric intensive care unit of a university-based children's hospital. Fifty-three volume-overloaded critically ill infants (age range, 4 days to 6 months) were divided into two groups: those with heart disease (31 infants) and those with lung disease (22 infants). Each patient received a single intravenous bolus dose of bumetanide. Doses, selected in sequential order, ranged from 0.005 to 0.100 mg/kg. Age was used as a continuous variable to determine its effects on the variability in the pharmacokinetics and pharmacodynamics of bumetanide. Hierarchical multiple regression analyses were used to assess the effects of age, disease, and other drugs on the variability in the effects of bumetanide.

RESULTS

Total clearance, renal clearance, and nonrenal clearance of bumetanide all increased with age (p < 0.05), but the ratio of renal clearance to total clearance remained constant at about 0.4. Half-life and mean residence time decreased markedly in the first month of life (p < 0.05). Bumetanide excretion rate normalized for dose also increased with increasing age. Patients with lung disease exhibited a significantly greater clearance and shorter half-life (p < 0.05) than those with heart disease, whereas volume of distribution was similar in both groups. The primary determinant of bumetanide excretion rate was the administered dose (73%). Dose-response curves for urine flow rate and electrolyte excretion were similar between disease groups. The time course of the effect of bumetanide excretion rate on pharmacodynamics responses was similar between disease groups, as was the duration of the diuretic effect.

CONCLUSIONS

The pharmacokinetics of bumetanide were influenced significantly by age and disease. Differences in pharmacokinetics between patients with lung and heart disease were primarily due to differences in total clearance. The administered dose of bumetanide and age were positive determinants of bumetanide excretion rate and pharmacodynamic responses. Pharmacodynamic responses as a function of bumetanide excretion rate were not significantly different between disease groups.

Pharmacokinetics of bumetanide in critically ill infants

OBJECTIVE

Define the pharmacokinetics of bumetanide after single intravenous doses in volume-overloaded critically ill infants.

METHODS

A prospective, open-label study was carried out in a group of 58 infants aged 0 to 6 months who required diuretic therapy. Each patient received a single dose of intravenous bumetanide. Doses selected in sequential order ranged from 0.005 to 0.10 mg/kg. Hematologic and serum chemistry studies were performed before and at 6 and 24 hours after bumetanide administration. Determinations of urine volume and chemistries were performed before (collected from -2 to -4 hours to time 0) and at 1, 2, 3, 4, 6, and 12 hours after bumetanide dosing. Serum samples collected at time 0 and at 5, 15, 30, 60, 120, 180, 240, 360, and 480 minutes and urine collected at time 0 and at 0 to 1, 1 to 2, 2 to 3, 3 to 4, 4 to 6, and 6 to 12 hours were analyzed for bumetanide concentration. Data were evaluated by standard noncompartmental pharmacokinetic techniques.

RESULTS

Peak serum bumetanide concentrations occurred at 5 minutes after bumetanide administration. Area under the curve and peak serum bumetanide concentrations showed linear increases over the twentyfold dose range; whereas beta volume of distribution, volume of distribution at steady state, clearance, renal clearance, half-life, and mean residence time values were independent of dose. Peak urinary excretion rates of bumetanide increased linearly with increasing doses. The mean percent of bumetanide recovered in the urine from 0 to 12 hours was 40% +/- 15% of the administered dose.

CONCLUSIONS

Distribution and elimination kinetics of bumetanide were similar in all patients. Elimination kinetics were first order over the dose range of 0.005 to 0.10 mg/kg. Pharmacokinetic parameter estimates (beta volume of distribution, volume of distribution at steady state, clearance, renal clearance, half-life, and mean residence time) were independent of the dose of bumetanide administered. Single doses of bumetanide up to 0.10 mg/kg appear to be well tolerated in acutely ill volume-overloaded infants aged 0 to 6 months.

Sodium depletion and maternal separation in the suckling rat increase its salt intake when adult

To establish whether neonatal sodium depletion increases the adult's avidity for NaCl, 12-day-old suckling pups were injected with the natriuretic-diuretic furosemide (1 mg) while with their dams. The injections surged plasma aldosterone, and when the rats were adult (70 days), their spontaneous intake of 3% NaCl was increased. Additional experiments investigated whether maternal separation has a similar effect and could thus be a source of individual variation in salt intake of the adult. Fifteen-day-old pups were separated from their dams for 24 h in an incubator. When adult, their intake of 3% NaCl was increased. Availability of saline during maternal separation obviated the effect. The increase in adult intake of 3% NaCl was specific insofar as drinking of water was not increased similarly. The results show that the adult rat's avidity for sodium can be increased by postnatal natriuresis and possibly stress. The implications of the findings are discussed.

Ototoxicity in developing mammals

Developing mammals are more sensitive to noise, chemical and drug-induced ototoxicity than adults, with maximum sensitivity occurring during periods of anatomical and functional maturation of the cochlea. Normal physiological development of resting potentials (the endocochlear potential) and sound-evoked potentials including cochlear microphonics, summating potentials, compound action potentials, auditory brainstem responses and more recently distortion-product otoacoustic emissions have been characterized in several species including rats, mice, kittens, gerbils and guinea pigs. All of these responses are significantly impaired following acoustic trauma and/or exposure to a variety of ototoxic agents including aminoglycoside antibiotics, loop diuretics, antithyroid and antitumor drugs (alpha-difluoromethylornithine) and excitatory amino acids. Coupled with physiological and anatomical development is the maturation of specific biochemical pathways, which may be vulnerable targets of environmental noise and chemicals, excitatory amino acids and therapeutic drugs with ototoxic potentials.

Comparison of two preservation solutions for erythrocyte transfusions in newborn infants

To determine whether one of the newer preservation solutions for packed red blood cells (PRBC) is safe and effective in the transfusion of the very low birth weight infant, we conducted a randomized trial comparing PRBC preserved with the anticoagulant solution mannitol-adenine-dextrose (AS-1) and PRBC preserved with citrate-phosphate-dextrose-adenine (CPDA-1). Sixteen infants (birth weight 863 +/- 218 gm) with a gestational age of 26 +/- 3 weeks received one to three small-volume replacement transfusions with PRBC, 17 ml/kg, preserved with either AS-1 or CPDA-1 in a double crossover design. Transfusion with AS-1-preserved PRBC resulted in an equivalent increase in hemoglobin concentration when adjustment was made for the difference in the hemoglobin concentration of the transfused PRBC. During the transfusion, the percentage decrease in serum glucose values was greater with the CPDA-1 preservative than with the AS-1 preservative (54% +/- 13% vs 42% +/- 11% at 1 hour; p < 0.001). No other significant difference in blood chemistry values was found. Urine output was unaffected by AS-1 in the posttransfusion period. We conclude that (1) small-volume PRBC transfusions with AS-1 can be used in the very low birth weight infant without apparent detriment, (2) AS-1-preserved cells are as effective as cells preserved with CPDA-1 for increasing hemoglobin concentration, and (3) the higher dextrose content of the AS-1-preserved blood allows for improved glucose homeostasis during transfusion.

Pharmacokinetics and pharmacodynamics of bumetanide in neonates treated with extracorporeal membrane oxygenation

Eleven term neonates treated with extracorporeal membrane oxygenation received bumetanide to treat volume overload. All patients had stable renal function, no history of prior diuretic therapy, and no overt evidence of hepatobiliary disease or hypoalbuminemia. Pretreatment creatinine clearance was 35.2 +/- 4.5 ml/min per 1.73 m2 (range, 20.3 to 57.5). Bumetanide, 0.095 +/- 0.003 mg/kg, was administered for 2 minutes into the postmembrane side of the extracorporeal membrane oxygenation circuit. Serial plasma and urine samples were collected for measurement of bumetanide and electrolyte concentrations. Total plasma and renal clearances for bumetanide were 0.63 +/- 0.11 and 0.16 +/- 0.04 ml/min per kilogram, respectively. The steady-state volume of distribution (0.44 +/- 0.03 L/kg) and the elimination half-life (13.2 +/- 3.8 hours) were greater than similar values reported in previous studies of bumetanide disposition in premature and term neonates who were not treated with extracorporeal membrane oxygenation. At observed rates of bumetanide excretion, the diuretic, natriuretic, and kaliuretic responses were linear. Significant diuresis, natriuresis, and kaliuresis were observed, although the duration of these effects was less than expected given the prolonged renal elimination of bumetanide. Nonrenal elimination of bumetanide was variable (47.2% to 96.9%) but higher than expected; this may explain the relatively brief diuretic and kaliuretic response.

Measurement of bumetanide in plasma and urine by high-performance liquid chromatography and application to bumetanide disposition

A high-performance liquid chromatographic method for the measurement of bumetanide in plasma and urine is described. Following precipitation of proteins with acetonitrile, bumetanide was extracted from plasma or urine on a 1-ml bonded-phase C18 column and eluted with acetonitrile. Piretanide dissolved in methanol was used as the internal standard. A C18 Radial Pak column and fluorescence detection (excitation wavelength 228 nm; emission wavelength 418 nm) were used. The mobile phase consisted of methanol-water-glacial acetic acid (66:34:1, v/v) delivered isocratically at a flow-rate of 1.2 ml/min. The lower limit of detection for this method was 5 ng/ml using 0.2 ml of plasma or urine. Nafcillin, but not other semi-synthetic penicillins, was the only commonly used drug that interfered with this assay. No interference from endogenous compounds was detected. For plasma, the inter-assay coefficients of variation of the method were 7.6 and 4.4% for samples containing 10 and 250 ng/ml bumetanide, respectively. The inter-assay coefficients of variation for urine samples containing 10 and 2000 ng/ml were 8.1 and 5.7%, respectively. The calibration curve was linear over the range 5-2000 ng/ml.