Torsemide (Torasemide) is a diuretic drug that causes water excretion by inhibiting the reabsorption of sodium and chloride in the ascending loop of Henle and distal renal tubules.
Torsemide Uses:
-
Edema:
- It is used for treating edema associated with heart failure and hepatic or renal disease.
-
Hypertension:
- Torsemide is indicted for the management of hypertension.
Note: It is not used as first line therapy for hypertension.
Torsemide dose in adults:
Note: Torsemide 20 mg = bumetanide 1 mg = furosemide 40 mg = ethacrynic acid 50 mg
Torsemide dose in patients with Edema:
-
Chronic renal failure:
- Oral: Initial: 20 mg once daily; may increase gradually by doubling dose until the desired diuretic response is obtained.
-
Heart failure:
- 10 to 20 mg orally once daily initially.
- The dose may be increased gradually by doubling dose until the desired diuretic response is obtained.
- The maximum dose is 200 mg/day
-
Hepatic cirrhosis:
- 5 to 10 mg orally once daily initially.
- The dose may be increased gradually by doubling dose until the desired diuretic response is obtained
- The maximum recommended single dose is 40 mg.
- Note: It should be given in combination with aldosterone antagonist or a potassium-sparing diuretic.
Torsemide dose in the treatment of Hypertension:
- 5 mg orally once daily initially;
- The dose may be increased to 10 mg once daily after 4-6 weeks if inadequate antihypertensive response.
Torsemide use in children:
The safety and efficacy of the drug in children is not known.
Torsemide pregnancy Risk Factor: C
- Animal reproduction studies showed some adverse outcomes.
Torsemide use during breastfeeding:
- Torsemide secretion in breast milk is unknown, however, diuretics can suppress lactation.
Torsemide dose adjustment in renal disease:
- There are no dosage adjustments provided in the manufacturer’s labeling.
- Higher doses may be required to achieve diuretic response.
Torsemide dose adjustment in liver disease:
- There are no dosage adjustments provided in the manufacturer’s labeling; use with caution.
- It is contraindicated in hepatic coma
Side Effects of Torsemide:
-
Cardiovascular:
- ECG Abnormality
- Chest Pain
-
Central Nervous System:
- Nervousness
-
Gastrointestinal:
- Constipation
- Diarrhea
- Dyspepsia
- Nausea
- Sore Throat
-
Neuromuscular & Skeletal:
- Arthralgia
- Myalgia
- Weakness
-
Renal:
- Polyuria
-
Respiratory:
- Rhinitis
- Cough
Contraindications to Torsemide:
- Hypersensitivity to torsemide and any component of the formulation
- Anuria
- Hepatic coma.
Warnings and precautions
-
Fluid and electrolyte losses:
- The effects of torsemide on fluid and electrolyte levels can be severe.
- Monitoring is necessary for hypokalemia (hypokalemia), hyponatremia (hypomagnesemia), hypocalcemia (hypochloremic alkalosis), hyponatremia (hypomagnesemia), hyponatremia and hypomagnesemia).
- Patients with electrolyte problems can be predisposed to serious arrhythmias.
-
Hyperuricemia:
- It can cause hyperuricemia and gout.
-
Nephrotoxicity:
- Monitors should be kept on the lookout for signs such as oliguria, azotemia and reversible rises in creatinine and BUN.
-
Ototoxicity:
- Tinnitus and hearing loss can be caused by severe renal impairment, excessive dosages, hypoproteinemia, or the use of aminoglycosides.
-
Allergy to sulfonamide ("sulfa")
- T-cell-mediated (type IV), reactions are observed when sulfa-containing drugs cause a maculopapular eruption.
- These drugs should not be used if you have severe reactions, such as Stevens Johnson syndrome or toxic epidermal neural neurolysis.
-
Insufficiency of the adrenal gland:
- Patients with Addison disease should not use Torsemide to treat hypertension.
-
Bariatric surgery
- Bariatric surgery should not be performed with diuretics as they can cause electrolyte disturbances or dehydration.
-
Diabetes:
- Patients with diabetes should use it.
-
Hepatic impairmen
- Hepatic encephalopathy can be caused by electrolyte or acid/base imbalance. You should not use it if you have cirrhosis.
Torsemide (torasemide): Drug Interaction
|
Ajmaline |
Sulfonamides may enhance the adverse/toxic effect of Ajmaline. Specifically, the risk for cholestasis may be increased. |
|
Alfuzosin |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Allopurinol |
Loop Diuretics may enhance the adverse/toxic effect of Allopurinol. Loop Diuretics may increase the serum concentration of Allopurinol. Specifically, Loop Diuretics may increase the concentration of Oxypurinol, an active metabolite of Allopurinol. |
|
Alpelisib |
May decrease the serum concentration of CYP2C9 Substrates (High risk with Inducers). |
|
Amikacin (Oral Inhalation) |
Loop Diuretics may enhance the nephrotoxic effect of Amikacin (Oral Inhalation). Loop Diuretics may enhance the ototoxic effect of Amikacin (Oral Inhalation). |
|
Aminoglycosides |
Loop Diuretics may enhance the adverse/toxic effect of Aminoglycosides. Specifically, nephrotoxicity and ototoxicity. |
|
Amphetamines |
May diminish the antihypertensive effect of Antihypertensive Agents. |
|
Angiotensin-Converting Enzyme Inhibitors |
Loop Diuretics may enhance the hypotensive effect of Angiotensin-Converting Enzyme Inhibitors. Loop Diuretics may enhance the nephrotoxic effect of Angiotensin-Converting Enzyme Inhibitors. |
|
Antidiabetic Agents |
Hyperglycemia-Associated Agents may diminish the therapeutic effect of Antidiabetic Agents. |
|
Antipsychotic Agents (Second Generation [Atypical]) |
Blood Pressure Lowering Agents may enhance the hypotensive effect of Antipsychotic Agents (Second Generation [Atypical]). |
|
Barbiturates |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Benperidol |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Beta2-Agonists |
May enhance the hypokalemic effect of Loop Diuretics. |
|
Bilastine |
Loop Diuretics may enhance the QTc-prolonging effect of Bilastine. |
|
Brigatinib |
May diminish the antihypertensive effect of Antihypertensive Agents. Brigatinib may enhance the bradycardic effect of Antihypertensive Agents. |
|
Brimonidine (Topical) |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Cardiac Glycosides |
Loop Diuretics may enhance the adverse/toxic effect of Cardiac Glycosides. Specifically, cardiac glycoside toxicity may be enhanced by the hypokalemic and hypomagnesemic effect of loop diuretics. |
|
Cefazedone |
May enhance the nephrotoxic effect of Loop Diuretics. |
|
Cefotiam |
Loop Diuretics may enhance the nephrotoxic effect of Cefotiam. |
|
Cefpirome |
Loop Diuretics may enhance the nephrotoxic effect of Cefpirome. |
|
Ceftizoxime |
Loop Diuretics may enhance the nephrotoxic effect of Ceftizoxime. |
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Cephalothin |
Loop Diuretics may enhance the nephrotoxic effect of Cephalothin. |
|
Cephradine |
May enhance the nephrotoxic effect of Loop Diuretics. |
|
CISplatin |
Loop Diuretics may enhance the nephrotoxic effect of CISplatin. Loop Diuretics may enhance the ototoxic effect of CISplatin. |
|
Corticosteroids (Orally Inhaled) |
May enhance the hypokalemic effect of Loop Diuretics. |
|
Corticosteroids (Systemic) |
May enhance the hypokalemic effect of Loop Diuretics. |
|
CycloSPORINE (Systemic) |
May enhance the adverse/toxic effect of Loop Diuretics. |
|
CYP2C9 Inducers (Moderate) |
May decrease the serum concentration of CYP2C9 Substrates (High risk with Inducers). |
|
CYP2C9 Inhibitors (Moderate) |
May increase the serum concentration of Torsemide. |
|
Dexmethylphenidate |
May diminish the therapeutic effect of Antihypertensive Agents. |
|
Diacerein |
May enhance the therapeutic effect of Diuretics. Specifically, the risk for dehydration or hypokalemia may be increased. |
|
Diazoxide |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
DULoxetine |
Blood Pressure Lowering Agents may enhance the hypotensive effect of DULoxetine. |
|
Eltrombopag |
May increase the serum concentration of OATP1B1/1B3 (SLCO1B1/1B3) Substrates. |
|
Empagliflozin |
May enhance the hypotensive effect of Loop Diuretics. |
|
Fosphenytoin |
May diminish the diuretic effect of Loop Diuretics. |
|
Gemfibrozil |
May increase the serum concentration of OATP1B1/1B3 (SLCO1B1/1B3) Substrates. See separate drug interaction monographs for agents listed as exceptions. |
|
Herbs (Hypertensive Properties) |
May diminish the antihypertensive effect of Antihypertensive Agents. |
|
Herbs (Hypotensive Properties) |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Hypotension-Associated Agents |
Blood Pressure Lowering Agents may enhance the hypotensive effect of Hypotension-Associated Agents. |
|
Ipragliflozin |
May enhance the adverse/toxic effect of Loop Diuretics. Specifically, the risk for intravascular volume depletion may be increased. |
|
Ivabradine |
Loop Diuretics may enhance the arrhythmogenic effect of Ivabradine. |
|
Levodopa-Containing Products |
Blood Pressure Lowering Agents may enhance the hypotensive effect of Levodopa-Containing Products. |
|
Licorice |
May enhance the hypokalemic effect of Loop Diuretics. |
|
Lithium |
Loop Diuretics may decrease the serum concentration of Lithium. Loop Diuretics may increase the serum concentration of Lithium. |
|
Lormetazepam |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Lumacaftor |
May decrease the serum concentration of CYP2C9 Substrates (High Risk with Inhibitors or Inducers). Lumacaftor may increase the serum concentration of CYP2C9 Substrates (High Risk with Inhibitors or Inducers). |
|
Methylphenidate |
May diminish the antihypertensive effect of Antihypertensive Agents. |
|
Molsidomine |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Naftopidil |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Neuromuscular-Blocking Agents |
Loop Diuretics may diminish the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Loop Diuretics may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. |
|
Nicergoline |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Nicorandil |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Nitroprusside |
Blood Pressure Lowering Agents may enhance the hypotensive effect of Nitroprusside. |
|
Opioid Agonists |
May enhance the adverse/toxic effect of Diuretics. Opioid Agonists may diminish the therapeutic effect of Diuretics. |
|
Pentoxifylline |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Phenytoin |
May diminish the diuretic effect of Loop Diuretics. |
|
Pholcodine |
Blood Pressure Lowering Agents may enhance the hypotensive effect of Pholcodine. |
|
Phosphodiesterase 5 Inhibitors |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Probenecid |
May enhance the adverse/toxic effect of Loop Diuretics. Probenecid may diminish the diuretic effect of Loop Diuretics. Probenecid may increase the serum concentration of Loop Diuretics. Management: Monitor for decreased diuretic effects or increased adverse effects of loop diuretics with concomitant use of probenecid. Bumetanide prescribing information recommends against concomitant use of probenecid. |
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Prostacyclin Analogues |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Quinagolide |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Reboxetine |
May enhance the hypokalemic effect of Loop Diuretics. |
|
Rifapentine |
May decrease the serum concentration of CYP2C9 Substrates (High risk with Inducers). |
|
RisperiDONE |
Loop Diuretics may enhance the adverse/toxic effect of RisperiDONE. |
|
Salicylates |
May diminish the diuretic effect of Loop Diuretics. Loop Diuretics may increase the serum concentration of Salicylates. |
|
Teriflunomide |
May increase the serum concentration of OATP1B1/1B3 (SLCO1B1/1B3) Substrates. |
|
Tobramycin (Oral Inhalation) |
Loop Diuretics may enhance the nephrotoxic effect of Tobramycin (Oral Inhalation). Loop Diuretics may enhance the ototoxic effect of Tobramycin (Oral Inhalation). |
|
Topiramate |
Loop Diuretics may enhance the hypokalemic effect of Topiramate. |
|
Warfarin |
Torsemide may increase the serum concentration of Warfarin. |
|
Xipamide |
May enhance the adverse/toxic effect of Loop Diuretics. Specifically, the risk of hypovolemia, electrolyte disturbances, and prerenal azotemia may be increased. |
|
Yohimbine |
May diminish the antihypertensive effect of Antihypertensive Agents. |
|
Amifostine |
Blood Pressure Lowering Agents may enhance the hypotensive effect of Amifostine. Management: When amifostine is used at chemotherapy doses, blood pressure lowering medications should be withheld for 24 hours prior to amifostine administration. If blood pressure lowering therapy cannot be withheld, amifostine should not be administered. |
|
Bile Acid Sequestrants |
May decrease the absorption of Loop Diuretics. |
|
Canagliflozin |
|
|
Dabrafenib |
May decrease the serum concentration of CYP2C9 Substrates (High risk with Inducers). Management: Seek alternatives to the CYP2C9 substrate when possible. If concomitant therapy cannot be avoided, monitor clinical effects of the substrate closely (particularly therapeutic effects). |
|
Dofetilide |
Loop Diuretics may enhance the QTc-prolonging effect of Dofetilide. Management: Monitor serum potassium and magnesium more closely when dofetilide is combined with loop diuretics. Some therapy modification may be required. |
|
Enzalutamide |
May decrease the serum concentration of CYP2C9 Substrates (High risk with Inducers). Management: Concurrent use of enzalutamide with CYP2C9 substrates that have a narrow therapeutic index should be avoided. Use of enzalutamide and any other CYP2C9 substrate should be performed with caution and close monitoring. |
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Foscarnet |
Loop Diuretics may increase the serum concentration of Foscarnet. |
|
Methotrexate |
May diminish the therapeutic effect of Loop Diuretics. Loop Diuretics may increase the serum concentration of Methotrexate. Methotrexate may increase the serum concentration of Loop Diuretics. Management: Monitor for increased methotrexate and/or loop diuretic levels/toxicity with concomitant use of these agents and monitor for decreased therapeutic effects of loop diuretics. Methotrexate and/or loop diuretic dose reductions may be necessary. |
|
MiFEPRIStone |
May increase the serum concentration of CYP2C9 Substrates (High risk with Inhibitors). Management: Use CYP2C9 substrates at the lowest recommended dose, and monitor closely for adverse effects, during and in the 2 weeks following mifepristone treatment. |
|
Nonsteroidal Anti-Inflammatory Agents |
May diminish the diuretic effect of Loop Diuretics. Loop Diuretics may enhance the nephrotoxic effect of Nonsteroidal Anti-Inflammatory Agents. Management: Monitor for evidence of kidney injury or decreased therapeutic effects of loop diuretics with concurrent use of an NSAID. Consider avoiding concurrent use in CHF or cirrhosis. Concomitant use of bumetanide with indomethacin is not recommended. |
|
Obinutuzumab |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. Management: Consider temporarily withholding blood pressure lowering medications beginning 12 hours prior to obinutuzumab infusion and continuing until 1 hour after the end of the infusion. |
|
Sodium Phosphates |
Diuretics may enhance the nephrotoxic effect of Sodium Phosphates. Specifically, the risk of acute phosphate nephropathy may be enhanced. Management: Consider avoiding this combination by temporarily suspending treatment with diuretics, or seeking alternatives to oral sodium phosphate bowel preparation. If the combination cannot be avoided, hydrate adequately and monitor fluid and renal status. |
|
Tolvaptan |
May increase the serum concentration of OATP1B1/1B3 (SLCO1B1/1B3) Substrates. |
|
Risk Factor X (Avoid combination) |
|
|
Bromperidol |
Blood Pressure Lowering Agents may enhance the hypotensive effect of Bromperidol. Bromperidol may diminish the hypotensive effect of Blood Pressure Lowering Agents. |
|
Desmopressin |
Loop Diuretics may enhance the hyponatremic effect of Desmopressin. |
|
Levosulpiride |
Loop Diuretics may enhance the adverse/toxic effect of Levosulpiride. |
|
Mecamylamine |
Sulfonamides may enhance the adverse/toxic effect of Mecamylamine. |
|
Promazine |
Loop Diuretics may enhance the QTc-prolonging effect of Promazine. |
Monitoring parameters:
- BP
- Blood glucose
- Renal function tests
- Serum electrolytes
- Diuretic effect
How to administer Torsemide?
It should be given orally as food slows the rate and reduces the extent of absorption and may reduce diuretic efficacy.
Mechanism of action of Torsemide:
- It inhibits sodium and chloride absorption in the ascending loops of Henle, and distal renal tubule.
- Although the excretion of calcium, sodium, chloride and magnesium is increasing, glomerular flow rate, renal plasma flow or an acid-base equilibrium remain constant.
Peak diuretic effect It is visible in 1 to 2 hours. The peak antihypertensive effect can be seen in 4 to 6 weeks (may take as long as 12 weeks).
The duration ofDiuresis can last 6-8 hours
Protein binding: >99%
Metabolism: Liver disease (80%) via CYP2C9, CYP2C8 or CYP2C18
Bioavailability: 80%
Half-life elimination: 3.5 Hours
Time to get therepeak plasma concentrationIt takes less than an hour. If administered with food, it may take up to half an hour.
Excretion: Urine (21%).
Torsemide Brand Names (International):
- Demadex
- Britomar
- Cardiotimide
- Dilast
- Diuver
- Dytor
- Examide
- Kamez
- Luprac
- Luretic
- Onced
- Setoram
- Sutril
- Sutrilneo
- Tomide
- Toradiv
- Toral
- Torem
- Torrem
- Torsem
- Torsid
- Torsix
- Trifas
- Tuosai
- Unat
Torsemide Brand Names in Pakistan:
No Brands Available in Pakistan.
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