Comprehensive analysis of a widely pharmaceutical, furosemide, and its degradation products in aquatic systems: Occurrence, fate, and ecotoxicity

Many pharmaceutical compounds end up in the environment due to incomplete removal by wastewater treatment plants (WWTPs). Some compounds are sometimes present in significant concentrations and therefore represent a risk to the aquatic environment. Furosemide is one of the most widely used drugs in the world. Considered as an essential drug by the World Health Organization, this powerful loop diuretic is used extensively to treat hypertension, heart and kidney failure and many other purposes. However, this important consumption also results in a significant release of furosemide in wastewater and in the receiving environment where concentrations of a few hundred ng/L to several thousand have been found in the literature, making furosemide a compound of great concern. Also, during its transport in wastewater systems and WWTPs, furosemide can be degraded by various processes resulting in the production of more than 74 by-products. Furosemide may therefore present a significant risk to ecosystem health due not only to its direct cytotoxic, genotoxic and hepatotoxic effects in animals, but also indirectly through its transformation products, which are poorly characterized. Many articles classify furosemide as a priority pollutant according to its occurrence in the environment, its persistence, its elimination by WWTPs, its toxicity and ecotoxicity. Here, we present a state-of-the-art review of this emerging pollutant of interest, tracking it, from its consumption to its fate in the aquatic environment. Discussion points include the occurrence of furosemide in various matrices, the efficiency of many processes for the degradation of furosemide, the subsequent production of degradation products following these treatments, as well as their toxicity.

Case report: Resolution of oligo-anuric acute kidney injury with furosemide administration in a cat following lily toxicity

Objective

To describe the successful outcome of a case of oligo-anuric acute kidney injury in a cat secondary to lily ingestion.

Case summary

A 12-week-old intact male domestic short-hair cat weighing 1.64 kg (3.6 lb) presented with a 12-h duration of vomiting and lethargy after exposure to lilies of the genera Lilium species 24 h prior to presentation. Severe azotemia (Creatinine 5.8 mg/dL, BUN > 100 mg/dL) and hyperkalemia (9.36 mmol/L) were noted on the day of presentation. Treatment of hyperkalemia was instituted with calcium gluconate, lactated ringers solution, dextrose, regular short-acting insulin, albuterol, and sodium bicarbonate, Oliguria to anuria was highly suspected based on a lack of urine production 21 h after hospitalization with intravenous fluid administration and a static bladder size. The cat was administered 4 mg/kg of furosemide, and urinated at 6 h following administration and continued to produce over 6 ml/kg/h of urine in the next 24 h. Two days following furosemide administration, the cat's hyperkalemia and azotemia resolved. The cat was discharged after 4 days of hospitalization, and a recheck revealed no persistent azotemia or hyperkalemia.

Unique information

Anuric acute kidney injury secondary to lily toxicity is associated with a poor prognosis, and the only treatment modality previously described is hemodialysis. The cat in this report was successfully managed with medical intervention and furosemide administration, with complete resolution of the acute kidney injury.

Occurrence and fate of an emerging drug pollutant and its by-products during conventional and advanced wastewater treatment: Case study of furosemide

Conventional wastewater treatment systems are not designed to remove pharmaceutical compounds from wastewater. These compounds can be degraded into many other transformation products which are hardly, if at all, studied. In this context, we studied the occurrence and degradation of furosemide, a very frequently detected diuretic, along with its known degradation products in several types of wastewater. Influent and effluent from the Seine-Centre Wastewater Treatment Plant (WWTP) (Paris, France) as well as outlet of residential care homes (Dordogne, France) were analyzed by Ultra-Performance Liquid Chromatography-tandem Mass Spectrometry (UPLC-MS/MS) to quantify furosemide and its known degradation products, saluamine and pyridinium of furosemide. Oxidation experiments (chlorination, ozonation and UV photolysis with hydrogen peroxide) were then performed on furosemide solutions and on water from residential care facilities to study the degradation of furosemide by potential advanced processes, and also to identify unknown oxidation products by high-resolution mass spectrometry. Furosemide was well degraded in Seine-Centre WWTP (>75%) but did not increase the concentrations of its main degradation products. Saluamine and pyridinium of furosemide were already present at similar concentrations to furosemide in the raw wastewater (∼2.5-3.5 μg.L^-1), and their removal in the WWTPs were very high (>80%). Despite their removal, the three compounds remained present in treated wastewater effluents at concentrations of hundreds of nanograms per liter. Chlorination degraded furosemide without pyridinium production unlike the other two processes. Chlorination and ozonation were also effective for the removal of furosemide and pyridinium in residential care home water, but they resulted in the production of saluamine. To our knowledge this is the first evidence of saluamine and pyridinium of furosemide in real water samples in either the particulate or dissolved phase.

Pharmacokinetics and bioavailability of furosemide in sheep

The pharmacokinetics and bioavailability of furosemide were determined following intravenous (IV), intramuscular (IM), and subcutaneous (SC) administrations at 2.5 mg/kg dose in sheep. The study was conducted on six healthy sheep in a three-way, three-period, crossover pharmacokinetic design with a 15-day washout period. In first period, furosemide was randomly administered via IV to 2 sheep, IM to 2 sheep and SC to 2 sheep. In second and third periods, each sheep received furosemide via different routes of administration with the 15-day washout period. Plasma concentrations were determined using a high-performance liquid chromatography assay and analyzed by noncompartmental method. The mean total clearance and volume of distribution at steady state following IV administration were 0.24 L h^-1  kg^-1 and 0.17 L/kg, respectively. The elimination half-life was similar for all administration routes. The mean peak plasma concentrations of IM and SC administration were 10.33 and 3.18 μg/ml at 0.33 and 0.42 hr, respectively. The mean bioavailability of IM and SC administration was 97.91% and 37.98%, respectively. The IM injection of furosemide may be the alternative routes in addition to IV. However, further research is required to determine the effect of dose and route of administration on the clinical efficacy of furosemide in sheep.

Evaluation of subcutaneously administered electrolyte solutions in experimentally dehydrated inland bearded dragons (Pogona vitticeps)

OBJECTIVE

To evaluate the effects of 3 electrolyte solutions administered SC to experimentally dehydrated inland bearded dragons (Pogona vitticeps).

ANIMALS

9 inland bearded dragons.

PROCEDURES

In a randomized, complete crossover study, experimental dehydration was induced by means of furosemide (10 mg/kg, SC, q 12 h for 4 doses), and then lactated Ringer solution, Plasma-Lyte A, or reptile Ringer solution (RRS; 1:1 mixture of 5% dextrose solution and isotonic crystalloid solution) was administered SC in a single 50-mL/kg dose in 3 treatments sessions separated by a minimum of 14 days. Food and water were withheld during treatment sessions. Plasma biochemical values, PCV, blood total solids and lactate concentrations, and plasma osmolarity were measured prior to (baseline) and 4 and 24 hours after fluid administration.

RESULTS

Administration of RRS resulted in severe hyperglycemia (mean ± SD plasma glucose concentration, 420 ± 62 mg/dL), compared with baseline values (190 ± 32 mg/dL), and this hyperglycemia persisted for at least 24 hours. It also resulted in significant reductions in plasma osmolarity and sodium and phosphorus concentrations, which were not observed after administration of the other 2 solutions. Administration of lactated Ringer solution caused no significant increase in blood lactate concentration.

CONCLUSIONS AND CLINICAL RELEVANCE

The changes in plasma glucose, sodium, and phosphorus concentrations and plasma osmolarity observed after SC administration of a single dose of RRS suggested this type of electrolyte solution should not be used for rehydration of bearded dragons. Rather, lactated Ringer solution or Plasma-Lyte A should be considered instead.

Acute Respiratory Failure after Administration of Hydrogen Peroxide as an Emetic in a Cat

OBJECTIVE AND CASE SUMMARY

This case report describes a 5-year-old domestic short-haired cat that was orally administered with 4 mL of 3% hydrogen peroxide by the owner after suspecting ingestion of a foreign body by the cat. Shortly after the administration, the cat developed severe respiratory distress. Thoracic radiography showed an interstitial-to-alveolar pulmonary pattern, while echocardiography and heart injury markers ruled out a cardiac origin. Intensive management with oxygen, diuretics, bronchodilators, and sedation resulted in survival of the cat without further respiratory complications.

NEW AND UNIQUE INFORMATION PROVIDED

To the best of our knowledge, this is the first report of a lung injury and acute respiratory failure after administration of hydrogen peroxide in a cat with successful management.

Coughing in dogs: what is the evidence for and against a cardiac cough?

Cough has been historically reported as a major clinical sign of cardiogenic pulmonary oedema in dogs. However, recent evidence appears to contradict the traditional dogmatic approach that linked cough to congestive heart failure in dogs. Here we use a question-based format to introduce and discuss the modern evidence regarding "cardiac cough" and the interpretation of this important but often misleading clinical sign.

Administration of fenoldopam in critically ill small animal patients with acute kidney injury: 28 dogs and 34 cats (2008-2012)

OBJECTIVE

To describe the clinical features and outcomes of critically ill dogs and cats with acute kidney injury (AKI) receiving fenoldopam infusions compared to patients with AKI that did not receive fenoldopam.

DESIGN

Retrospective clinical study from May 1, 2008 until June 1, 2012.

SETTING

Private emergency and specialty referral hospital.

ANIMALS

Client-owned dogs (28) and cats (34) with AKI that received fenoldopam compared with similar patients with AKI (30 dogs and 30 cats) that did not.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The medical records of 62 critically ill dogs and cats with AKI that received fenoldopam were reviewed. Presenting clinical signs, physical examination findings, and primary and secondary disease processes were identified in all patients. The mean number of days on fenoldopam was 1.5 days (range 0.3-4.0 days) for dogs and 1.9 days (range 1.0-4.0 days) for cats. Eleven of 28 (39%) dogs survived to discharge and 13 of 34 (38%) of the cats survived to discharge. Of the animals in the group receiving fenoldopam that died, the majority (84%) were euthanized. Potential adverse reactions were evaluated, with hypotension being the most commonly encountered adverse effect (7% of fenoldopam group [FG] dogs and 23% of FG cats). When compared with patients with AKI that did not receive fenoldopam, no significant differences were found between the groups with regards to survival, length of hospital stay, adverse effects, or changes in creatinine, BUN, or sodium concentrations except that patients receiving fenoldopam were significantly more likely to have received other renally active medications.

CONCLUSIONS

In this study of patients with AKI, fenoldopam administration at 0.8 μg/kg/min in dogs and 0.5 μg/kg/min in cats appeared relatively safe but was not associated with improvement in survival to discharge, length of hospital stay, or improvement in renal biochemical parameters when compared to patients with AKI not receiving fenoldopam.

Non-natriuretic doses of furosemide: potential use for decreasing the workload of the renal outer medulla with minimal magnesium wasting in the rat

BACKGROUND/AIMS

Since furosemide (FS) inhibits active Na(+) reabsorption by medullary thick ascending limb (mTAL) in the renal outer medulla, it may decrease its work during periods of low O2 supply to deep in the renal outer medulla. This study was designed to demonstrate that there may be a dose of FS would reduce its metabolic work while preventing the excessive loss of magnesium (Mg(2+)). Mg(2+) is important because the ATP needed to perform work must have bound Mg(2+) to it.

METHODS

Rats were injected intraperitoneally with a range of doses of FS. The measured outcomes were urine flow rate and parameters of functions of the mTAL (i.e. urine and renal papillary osmolality and urinary excretion of Na(+), Cl(-), K(+) and Mg(2+), and concentrations of Mg(2+) in serum).

RESULTS

The urine flow rate increased significantly starting at 2.4 mg FS/kg. The renal papillary osmolality decreased at ≥0.4 mg FS/kg, and the large detectable natriuresis started at 1.6 mg FS/kg. At this latter dose, the urinary excretion of Mg(2+) rose significantly.

CONCLUSION

In rats, the non-natriuretic dose of FS may reduce the work of the mTAL. The earliest indicator of reduced work in the mTAL appears to be a decrease in urine osmolality rather than a rise in urine flow rate. Higher doses of FS should be avoided, as they induce high rates of Mg(2+) excretion, which can deplete the body of this essential electrolyte.

Unexpected effect of furosemide on radioiodine urinary excretion in patients with differentiated thyroid carcinomas treated with iodine 131

BACKGROUND

In patients receiving (131)I for therapeutic purposes, diuretics are frequently used in an attempt to accelerate elimination of unbound radioiodine, reduce its adverse effects, and shorten the hospital stay. The aims of our study were to investigate the influence of furosemide therapy on urinary excretion of (131)I in patients with differentiated thyroid cancer (DTC), referred to radioiodine ablation after thyroidectomy, and to investigate whether diuretics are useful in daily practice in patients with DTC.

METHODS

Forty-three patients with DTC who had normal renal function and low (131)I uptake in cervical region (3.55 +/- 3.45%) were included in this study. The furosemide (20 mg) and potassium chloride (250 mg) were given orally to 23 patients 3 hours after the (131)I administration, and then q8h for 3 days. Twenty patients did not receive either furosemide or potassium chloride. After (131)I administration, the patients collected their urine for 3 days, and radioactivity of urine sample from each micturition was expressed as percentage of the administered dose. Radioactivity of blood samples was measured after 72 hours, and the values were corrected for decay of (131)I and expressed in relation to the administered dose. Initial whole-body measurement (immediately after (131)I administration) and the whole-body measurement after 72 hours were recorded for all patients. The 72-hour whole-body measurement was corrected for decay of (131)I, and expressed as a percentage of the initial whole-body measurement.

RESULTS

Urinary excretion of (131)I was significantly lower in the patients who were taking furosemide and potassium chloride compared with the control group. The whole-body measurements after 72 hours (13.22 +/- 6.55% vs. 8.24 +/- 3.39% of the initial; p < 0.01, respectively) and the blood radioactivity (34.66 +/- 24.84 vs. 11.64 +/- 8.32 cpm/mL per 1 MBq of administered (131)I, p < 0.01) were found to be unexpectedly higher in the patients who were taking furosemide and potassium chloride compared with the control group.

CONCLUSION

Our results demonstrated that furosemide given as an adjuvant medication in patients with DTC causes a significant decrease in urinary excretion of radioiodine and its higher blood concentration. Therefore, furosemide should not be recommended as an adjuvant therapy to radioiodine ablation in patients with DTC previously iodine depleted by low-iodine diet.