Brand name: Demadex
Drug class: Loop Diuretics

Medically reviewed by Drugs.com on Sep 10, 2024. Written by ASHP.

Introduction

A sulfonamide, loop-type diuretic and antihypertensive agent.^{1 12 13 14}

Uses for Torsemide

Edema

Management of edema associated with heart failure^{1 14 524} or hepatic¹ or renal¹ disease (including chronic renal failure).^{12 13 14}

Most experts state that all patients with symptomatic heart failure who have evidence for, or a history of, fluid retention generally should receive diuretic therapy in conjunction with moderate sodium restriction, an agent to inhibit the renin-angiotensin-aldosterone (RAA) system (e.g., ACE inhibitor, angiotensin II receptor antagonist, angiotensin receptor-neprilysin inhibitor [ARNI]), a β-adrenergic blocking agent (β-blocker), and in selected patients, an aldosterone antagonist.^{524 700 713}

Hypertension

Management of hypertension alone or in combination with other classes of antihypertensive agents.^{1 3 12 13 1200}

Not considered a preferred agent for initial management of hypertension according to current evidence-based hypertension guidelines; other agents (i.e., ACE inhibitors, angiotensin II receptor antagonists, calcium-channel blockers, thiazide diuretics) are preferred for initial management.^{501 502 503 504 1200}

Some experts state that loop diuretics (e.g., bumetanide, furosemide, torsemide) are preferred over thiazides in patients with moderate to severe chronic kidney disease (CKD)^{502 504 1200} or symptomatic heart failure.^{524 1200}

Individualize choice of therapy; consider patient characteristics (e.g., age, ethnicity/race, comorbidities, cardiovascular risk) as well as drug-related factors (e.g., ease of administration, availability, adverse effects, cost).^{501 502 503 504 515 1200 1201}

A 2017 ACC/AHA multidisciplinary hypertension guideline classifies BP in adults into 4 categories: normal, elevated, stage 1 hypertension, and stage 2 hypertension.¹²⁰⁰ (See Table 1.)

Source: Whelton PK, Carey RM, Aronow WS et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71:e13-115.

Individuals with SBP and DBP in 2 different categories (e.g., elevated SBP and normal DBP) should be designated as being in the higher BP category (i.e., elevated BP).

The goal of hypertension management and prevention is to achieve and maintain optimal control of BP.¹²⁰⁰ However, the BP thresholds used to define hypertension, the optimum BP threshold at which to initiate antihypertensive drug therapy, and the ideal target BP values remain controversial.^{501 503 504 505 506 507 508 515 523 526 530 1200 1201 1207 1209 1222 1223 1229}

The 2017 ACC/AHA hypertension guideline generally recommends a target BP goal (i.e., BP to achieve with drug therapy and/or nonpharmacologic intervention) of <130/80 mm Hg in all adults regardless of comorbidities or level of atherosclerotic cardiovascular disease (ASCVD) risk.¹²⁰⁰ In addition, an SBP goal of <130 mm Hg generally is recommended for noninstitutionalized ambulatory patients ≥65 years of age with an average SBP of ≥130 mm Hg.¹²⁰⁰ These BP goals are based upon clinical studies demonstrating continuing reduction of cardiovascular risk at progressively lower levels of SBP.^{1200 1202 1210}

Other hypertension guidelines generally have based target BP goals on age and comorbidities.^{501 504 536} Guidelines such as those issued by the JNC 8 expert panel generally have targeted a BP goal of <140/90 mm Hg regardless of cardiovascular risk, and have used higher BP thresholds and target BPs in elderly patients^{501 504 536} compared with those recommended by the 2017 ACC/AHA hypertension guideline.¹²⁰⁰

Some clinicians continue to support previous target BPs recommended by JNC 8 due to concerns about the lack of generalizability of data from some clinical trials (e.g., SPRINT study) used to support the 2017 ACC/AHA hypertension guideline and potential harms (e.g., adverse drug effects, costs of therapy) versus benefits of BP lowering in patients at lower risk of cardiovascular disease.^{1222 1223 1224 1229}

Consider potential benefits of hypertension management and drug cost, adverse effects, and risks associated with the use of multiple antihypertensive drugs when deciding a patient's BP treatment goal.^{1200 1220 1229}

For decisions regarding when to initiate drug therapy (BP threshold), the 2017 ACC/AHA hypertension guideline incorporates underlying cardiovascular risk factors.^{1200 1207} ASCVD risk assessment is recommended by ACC/AHA for all adults with hypertension.¹²⁰⁰

ACC/AHA currently recommend initiation of antihypertensive drug therapy in addition to lifestyle/behavioral modifications at an SBP ≥140 mm Hg or DBP ≥90 mm Hg in adults who have no history of cardiovascular disease (i.e., primary prevention) and a low ASCVD risk (10-year risk <10%).¹²⁰⁰

For secondary prevention in adults with known cardiovascular disease or for primary prevention in those at higher risk for ASCVD (10-year risk ≥10%), ACC/AHA recommend initiation of antihypertensive drug therapy at an average SBP ≥130 mm Hg or an average DBP ≥80 mm Hg.¹²⁰⁰

Adults with hypertension and diabetes mellitus, CKD, or age ≥65 years are assumed to be at high risk for cardiovascular disease; ACC/AHA state that such patients should have antihypertensive drug therapy initiated at a BP ≥130/80 mm Hg.¹²⁰⁰ Individualize drug therapy in patients with hypertension and underlying cardiovascular or other risk factors.^{502 1200}

In stage 1 hypertension, experts state that it is reasonable to initiate drug therapy using the stepped-care approach in which one drug is initiated and titrated and other drugs are added sequentially to achieve the target BP.¹²⁰⁰ Initiation of antihypertensive therapy with 2 first-line agents from different pharmacologic classes recommended in adults with stage 2 hypertension and average BP >20/10 mm Hg above BP goal.¹²⁰⁰

Torsemide Dosage and Administration

General

• The manufacturers state that since oral and IV doses of torsemide are therapeutically equivalent, torsemide dosage is identical for oral or IV administration.^{1 12}

Edema

• Hospitalization of the patient during initiation of therapy is advisable for patients with hepatic cirrhosis and ascites or chronic renal failure.^{1 b 12 13}

• Chronic use of any diuretic in hepatic disease has not been adequately studied.^{1 12 13}

• For the management of fluid retention (e.g., edema) associated with heart failure, experts state that diuretics should be administered at a dosage sufficient to achieve optimal volume status and relieve congestion without inducing an excessively rapid reduction in intravascular volume, which could result in hypotension, renal dysfunction, or both.⁵²⁴

Monitoring and BP Treatment Goals

• Monitor BP regularly (i.e., monthly) during therapy and adjust dosage of the antihypertensive drug until BP controlled.¹²⁰⁰

• Assess patient's renal function and electrolytes 2–4 weeks after initiation of diuretic therapy.¹²⁰⁰

• If unacceptable adverse effects occur, discontinue drug and initiate another antihypertensive agent from a different pharmacologic class.¹²¹⁶

• If adequate BP response not achieved with a single antihypertensive agent, either increase dosage of single drug or add a second drug with demonstrated benefit and preferably a complementary mechanism of action (e.g., ACE inhibitor, angiotensin II receptor antagonist, calcium-channel blocker).^{1200 1216} Many patients will require at least 2 drugs from different pharmacologic classes to achieve this BP goal; if goal BP still not achieved with 2 antihypertensive agents, add a third drug.^{1200 1216 1220}

Administration

Administer orally, by direct IV injection, or by continuous IV infusion.^{1 12 13 14}

Oral Administration

Administer orally without regard to meals.^{1 12 13}

IV Administration

May use IV administration when a rapid onset of diuresis is desired or when oral therapy is not practical.^{1 12}

If torsemide is administered through an IV line, flush the IV line with 0.9% sodium chloride injection before and after administration.^{12 14}

Dilution

For IV infusion, dilute in 5% dextrose, 0.9% sodium chloride, or 0.45% sodium chloride injection.^{12 14}

Rate of Administration

For direct IV injection, administer slowly over a period of 2 minutes.^{1 12 14}

Administer IV injections of torsemide either slowly over 2 minutes (“bolus”) or as a continuous infusion.^{1 12 14}

Dosage

Adults

Edema

Heart Failure

Oral

Initially, 10–20 mg daily, given as a single dose.^{1 524} Increase as necessary by approximately doubling daily dosage until desired diuresis is attained.^{1 12} Single doses exceeding 200 mg not adequately studied.^{1 12 13 524} Some experts recommend initiating at a low dosage and increasing the dosage until urine output increases and weight decreases, generally by 0.5–1 kg daily.⁵²⁴

IV

Initially, 10–20 mg, given as a single dose.^{1 12 14} Increase as necessary by approximately doubling dosage until desired diuresis is attained.^{1 12 14} Single doses exceeding 200 mg not adequately studied.^{1 12 14}

Hypertension

Oral

Initially, 5 mg once daily.^{1 12 13} If adequate hypotensive response not attained in 4–6 weeks, may increase dosage to 10 mg once daily.^{1 12 13} If adequate response not observed with 10 mg once daily, an additional antihypertensive agent should be added to antihypertensive therapy.^{1 12 13}

Some experts state usual dosage is 5–10 mg once daily.¹²⁰⁰

IV

Initially, 5 mg once daily.^{1 12 14} If adequate hypotensive response not attained in 4–6 weeks, may increase dosage to 10 mg once daily.^{1 12 14} If adequate response not observed with 10 mg once daily, an additional antihypertensive agent should be added to antihypertensive therapy.^{1 12 14}

Prescribing Limits

Adults

Edema

Heart Failure

Oral

Maximum of 200 mg as a single dose (daily).^{1 12 13}

IV

Maximum of 200 mg as a single dose (daily).^{1 12 14}

Hypertension

Oral

Maximum of 10 mg once daily.^{1 12 13}

IV

Maximum of 10 mg once daily.^{1 12 14}

Special Populations

Renal Impairment

Edema

Edema Associated with Chronic Renal Failure

Oral or IV

In adults, initially, 20 mg once daily.^{1 14} Increase as necessary by approximately doubling dosage until desired diuresis is attained.^{1 14} Single doses exceeding 200 mg not adequately studied.^{1 12 13 14}

Hepatic Impairment

Chronic use in hepatic disease not adequately studied.^{1 12 13}

Edema

Edema Associated with Hepatic Cirrhosis

Oral or IV

In adults, initially, 5–10 mg once daily, given concomitantly with an aldosterone antagonist or a potassium-sparing diuretic.^{12 13 14} Increase as necessary by approximately doubling dosage until desired diuresis is attained.^{12 13 14} Single doses exceeding 40 mg not adequately studied.^{1 12 13 14}

Cautions for Torsemide

Contraindications

• Anuria.^{1 12 13 14}

• Known hypersensitivity to torsemide or to sulfonylureas.^{1 12 13 14}

Warnings/Precautions

Warnings

Hepatic Effects

Sudden alterations of electrolyte balance in patients with cirrhosis may precipitate hepatic coma; use with caution in patients with hepatic cirrhosis and ascites.^{1 12 13 14}

Therapy in such patients is best initiated in the hospital.^{1 14} Use an aldosterone antagonist or potassium-sparing agent concomitantly with torsemide to prevent hypokalemia and metabolic alkalosis in such patients.^{1 12 13 14}

Ototoxicity

Tinnitus and hearing loss, usually reversible, have been observed following rapid IV injection of other loop diuretics and following oral torsemide administration.^{1 12 13 14} Administer IV slowly (over 2 minutes); do not exceed 200 mg as a single dose.^{1 12 14}

Fluid, Electrolyte, and Cardiovascular Effects

Observe carefully for manifestations of fluid and electrolyte depletion (e.g., dryness of mouth, thirst, weakness, lethargy, drowsiness, restlessness, muscle pains or cramps, muscular fatigue, hypotension, oliguria, tachycardia, nausea, vomiting).^{1 12 13 14}

Excessive diuresis may cause dehydration and blood volume reduction with circulatory collapse and possibly vascular thrombosis and embolism, particularly in geriatric patients.^{1 12 13 14}

Laboratory changes may include altered serum concentrations of sodium, chloride, and potassium; acid-base abnormalities; and increased BUN.^{1 12} If electrolyte imbalance, hypovolemia, or prerenal azotemia develops, torsemide should be discontinued until the abnormality is corrected; treatment then may be restarted at a reduced dosage.^{1 12 13 14}

Risk of hypokalemia, especially with brisk diuresis, with inadequate oral electrolyte intake, in those with cirrhosis, or during concomitant use of corticosteroids or ACTH.^{1 12} Risk of arrhythmias secondary to hypokalemia in patients with cardiovascular disease, especially those receiving concomitant therapy with a cardiac glycoside.^{1 12 13}

Periodically monitor serum potassium and other electrolyte concentrations.^{1 12 13 14}

General Precautions

Endocrine Effects

Possible increased blood glucose concentrations; hyperglycemia occurred rarely. ^{1 12 13 14}

Renal and Electrolyte Effects

Small, dose-related, reversible increases in BUN, S_cr, and uric acid concentrations reported.^{1 14 12} Symptomatic gout reported at an incidence similar to placebo.^{1 12 13 14}

Slight alterations in calcium and magnesium concentrations.^{1 12 13}

Other Effects

Increases in total plasma cholesterol concentrations may occur; usually subside during chronic therapy.^{1 12 13 14}

Increases in plasma triglyceride concentrations reported.^{1 12 13}

In long-term studies, no clinically important differences in lipid profiles compared to baseline.^{1 12 14}

No clinically important effects on hemoglobin; hematocrit; WBC, erythrocyte, or platelet counts; or serum alkaline phosphatase concentrations.^{1 12 13 14}

Specific Populations

Pregnancy

Category B.^{1 12 13}

Lactation

Not known whether torsemide is distributed into milk.^{1 12 13 14} Caution if used in nursing women.^{1 12 13 14}

Pediatric Use

Safety and efficacy not established.^{1 12 13 14}

Renal calcifications reported in severely premature infants with edema secondary to patent ductus arteriosus and hyaline membrane disease receiving another loop diuretic.^{1 12 14} Increased risk of persistent patent ductus arteriosus in premature neonates with hyaline membrane disease receiving another loop diuretic also has been reported.^{1 12 13 14}

Geriatric Use

No substantial differences in safety and efficacy relative to younger adults.^{1 12 13 14}

Renal Impairment

Seizures reported in patients with acute renal failure receiving higher than recommended dosages of torsemide.^{1 12 13}

Common Adverse Effects

Headache, excessive urination, dizziness, rhinitis, asthenia, diarrhea, ECG abnormality, increased cough.^{1 12 13 14}

Drug Interactions

Specific Drugs

Torsemide Pharmacokinetics

Absorption

Bioavailability

Bioavailability is approximately 80%.¹

Onset

Following oral administration, onset of diuresis occurs within 1 hour; maximal effect during the first or second hour.^{1 12}

Following IV administration, onset of diuresis occurs within 10 minutes; maximal effect within 1 hour.^{1 12}

Duration

Independent of the route of administration, diuretic effect persists 6–8 hours following oral or IV administration.^{1 12}

Food

Food delays the time to peak plasma concentration following oral dosing but does not affect extent of absorption or diuretic activity.^{1 12}

Plasma Concentrations

Following oral administration, peak plasma concentrations achieved within 1 hour.¹

Distribution

Extent

Not known whether torsemide is distributed into milk.^{1 12 13 14}

Plasma Protein Binding

>99%.^{1 12}

Elimination

Metabolism

Hepatic metabolism accounts for approximately 80% of total clearance.^{1 12} Carboxylic acid derivative, the major metabolite, is inactive.^{1 12 13 14}

Elimination Route

Urinary excretion accounts for approximately 20% of total clearance in patients with normal renal function.^{1 12} Most renal clearance occurs via active secretion of the drug by the proximal tubules into tubular urine.^{1 12}

Half-life

Approximately 3.5 hours.^{1 12 13 14}

Special Populations

In patients with decompensated heart failure, hepatic and renal clearance are reduced, resulting in delivery of less drug to the intraluminal site of action and decreased natriuretic effect.^{1 12 13 14} Total clearance is about half of that of healthy individuals; half-life and AUC increased.^{1 12 13 14}

In patients with renal failure, renal clearance (but not total clearance) is reduced, resulting in delivery of less drug to the intraluminal site of action and decreased natriuretic effect.^{1 12 13 14}

In patients with hepatic cirrhosis, renal clearance (but not total clearance) and half-life are increased.^{1 12 13 14}

In geriatric patients, decreased renal clearance.^{1 12 13 14}

Stability

Storage

Oral

Tablets

15–30°C.^{1 12 13}

Parenteral

Injection

20–25°C.^{1 14} Do not freeze.^{1 14}

Actions

• Acts from within the lumen of the thick ascending portion of the loop of Henle, where it inhibits the sodium/potassium/chloride carrier system.^{1 12 13 14}

• Increases urinary excretion of sodium, chloride, and water without having an important effect on glomerular filtration rate, renal plasma flow, or acid-base balance.^{1 12 13 14}

Advice to Patients

• Risks associated with excessive fluid loss or electrolyte imbalance.^{1 12}

• Potential for postural hypotension; importance of rising slowly from a seated position.¹

• Importance of informing patients with diabetes mellitus that blood glucose concentrations may increase.¹

• Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as any concomitant illnesses.¹

• Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.¹

• Importance of informing patients of other important precautionary information.¹ (See Cautions.)

Additional Information

The American Society of Health-System Pharmacists, Inc. represents that the information provided in the accompanying monograph was formulated with a reasonable standard of care, and in conformity with professional standards in the field. Readers are advised that decisions regarding use of drugs are complex medical decisions requiring the independent, informed decision of an appropriate health care professional, and that the information contained in the monograph is provided for informational purposes only. The manufacturer’s labeling should be consulted for more detailed information. The American Society of Health-System Pharmacists, Inc. does not endorse or recommend the use of any drug. The information contained in the monograph is not a substitute for medical care.

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

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Frequently asked questions

• What are the equivalent dosages of bumetanide, furosemide & torsemide?

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