Severe musculoskeletal symptoms during continuous infusion of bumetanide

Background: The continuous infusion of the loop diuretic, bumetanide, has been shown to be effective in the treatment of severe refractory edema. Musculoskeletal symptoms have been reported with bumetanide following both oral and intermittent IV bolus therapy, It has been suggested that these adverse effects do not occur with continuous infusion. We describe, however, a series of patients with heart failure who developed severe disabling musculoskeletal symptoms during the continuous infusion of bumetanide. Objective: To evaluate the characteristics of bumetanide-induced musculoskeletal symptoms during continuous IV infusion in patients with severe heart failure. Methods: Heart failure patients receiving continuous infusions of bumetanide were monitored for the development of musculoskeletal symptoms. For patients who experienced the-adverse reaction, data were collected on demographics, medical diagnoses, concurrent medications, the diuretic regimen, symptoms, time course of the reaction, laboratory findings, alternative therapy, and outcomes. Results: Of 34 patients who received continuous infusions of bumetanide, eight patients experienced a total of 11 episodes of severe musculoskeletal symptoms. All patients had severe congestive heart failure and refractory edema. The reaction was most severe at infusion rates of approximately 2 mg/h and was not associated with any specific laboratory abnormality. The symptoms resolved completely after discontinuing the bumetanide therapy. In two of the patients, the adverse reaction was precipitated again during rechallenge with the bumetanide infusion. Patients who were given an equivalent or higher dose of a continuous furosemide infusion, diuresed without experiencing musculoskeletal symptoms. Conclusions: The continuous IV infusion of the loop diuretic, bumetanide, may result in severe, disabling musculoskeletal symptoms. The reaction appears to be dose related, without specific risk factors, and is reversible on discontinuation of the infusion. Patients who experience this reaction may be successfully diuresed with equivalent doses of a furosemide infusion.