Use of Furosemide for Milk-Alkali Syndrome–Reply–I

Abstract

Dr Homler raises an issue that has been a recent subject of heated discussions. The use of furosemide in management of severe hypercalcemia was beyond the scope of my review article, but I am happy to share my opinion. The article by LeGrand et al that Dr Homler cites concluded that the common practice of furosemide use in management of hypercalcemia is not evidence based. However, it is a well-recognized, evidence-based fact that furosemide induces hypercalciuria and decreases serum calcium levels.1 LeGrand et al do not disagree with these facts. Their claim is that only “a paucity” of evidence shows that furosemide is able to achieve complete “normalization” of serum calcium. The conclusion that furosemide should not be used for hypercalcemia was partly based on the assumption that adequate rehydration and fluid balance monitoring are not standard practice in this clinical setting. That is a very controversial conclusion with which I, along with many other clinicians, do not necessarily agree.1 There is no evidence that alkalosis and renal insufficiency will be exacerbated by diuresis as long as liberal and monitored hydration is used. The reports that conclude that furosemide should no longer be used in management of hypercalcemia are grossly exaggerated.