Key result
Furosemide dosing exceeds guidelines in ~49% of NICUs, primarily for cardiac overload and oligo-anuria.
Why the study?
Furosemide is often administered off-label in premature neonates, for respiratory conditions, and at higher-than-recommended doses, prompting an investigation into its real-world use in Italian neonatal intensive care units relative to current guidelines.
Cross-Sectional (n=57)
Yes
Furosemide is frequently used off-label and at higher-than-recommended doses in Italian NICUs for both approved and unapproved indications.
Suggests need for dosing vigilance in NICUs; leaves open neonatal safety and efficacy questions.
BACKGROUND: Furosemide is approved in full term neonates to treat edema associated with congestive heart failure, cirrhosis and renal diseases. It is often administered off-label in premature neonates, to treat respiratory conditions and at doses greater-than-recommended. We conducted a national survey on behalf of the Neonatal Pharmacotherapy Study Group of the Italian Society of Neonatology (SIN), to investigate its use in Italian neonatal intensive care units (NICUs), in conformity with current guidelines. METHODS: Between December 2016 and June 2017, a 14-item multiple-choice online questionnaire was sent to all NICU directors from the SIN directory. Gestational age, route of administration, posology, indications, referenced guidelines, adverse effects monitoring and the presence of Paediatric Cardiology or Cardiosurgery service on site were assessed. A chi-square test was performed 1) to evaluate differences in the distribution of responses between NICUs administering furosemide at doses higher-than-recommended; 2) to compare the proportion of NICUs administering furosemide at high doses in institutions with versus without a Paediatric Cardiology or Cardiosurgery service. RESULTS: The response rate was 50% (57/114). The intravenous and oral routes were chosen primarily; the intravenous administration in single doses predominated over continuous infusion. Its main therapeutic indications were congestive heart failure/overload (94.7%) and oligo-anuria (87.7%) however furosemide was also frequently used for broncopulmonary dysplasia (50.9%) and respiratory distress syndrome and/or transient tachypnea of the newborn (24.6%). In 28/57 NICUs furosemide was administered at doses higher-than-recommended. In most NICUs the same posology was used in term and preterm neonates. Compared to the total sample, a larger proportion of NICUs administering doses greater-than-recommended referenced current literature for reasons to do so (19.3 and 32.1% respectively). The presence of a Paediatric Cardiology or Cardiosurgery service on site did not correlate with the chosen posology. The majority of NICUs performed acoustic test and renal ultrasound for furosemide exposure greater than 2 weeks. CONCLUSIONS: In Italian NICUs, furosemide is commonly prescribed to term and preterm newborns for label and unlabeled indications. Doses greater-than-recommended are frequently administered. Such use is not necessarily inappropriate. More research is required to assess the efficacy and safety of unlabeled use.
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Manfredini et al. (2020) conducted a cross-sectional in Furosemide use in neonates (n=57). Furosemide administration practices was evaluated on Proportion of NICUs administering furosemide at doses higher than recommended. In 49% of surveyed Italian neonatal intensive care units, furosemide is administered at doses higher than recommended by guidelines, primarily for cardiac overload and oligo-anuria.
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