Torsemide: Advanced Loop Diuretic for Effective Fluid Management
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Synonyms | |||
Torsemide is a potent loop diuretic indicated for the treatment of edema associated with congestive heart failure, renal disease, and hepatic cirrhosis. It acts on the ascending limb of the loop of Henle to inhibit the sodium-potassium-chloride cotransporter, resulting in a significant increase in the excretion of water, sodium, and chloride. This mechanism provides a predictable and sustained diuretic effect, making it a cornerstone therapy in managing fluid overload in various clinical settings. Its pharmacokinetic profile, including reliable oral bioavailability and a longer half-life compared to furosemide in some patients, supports its use in both acute and chronic care.
Features
- Chemical Name: 1-isopropyl-3-[(4-m-toluidino-3-pyridyl) sulfonyl] urea
- Available Strengths: 5 mg, 10 mg, 20 mg, and 100 mg oral tablets; 10 mg/mL intravenous solution
- Mechanism of Action: Selective inhibition of the Na⁺-K⁺-2Cl⁻ cotransporter in the thick ascending limb of the loop of Henle
- Onset of Action: Oral: within 60 minutes; IV: within 10 minutes
- Peak Effect: 1–2 hours (oral); duration of action 6–8 hours
- Bioavailability: Approximately 80% (oral administration)
- Protein Binding: Extensive (≥97%), primarily to albumin
- Metabolism: Hepatic, primarily via CYP2C9; major metabolite is M1 (inactive)
- Excretion: Primarily renal (80%), with some fecal elimination
- Half-life: 3.5 hours in healthy subjects; may be prolonged in renal or hepatic impairment
Benefits
- Promotes rapid and significant fluid removal, reducing symptoms of pulmonary and peripheral edema
- Provides predictable diuresis with a favorable dose-response relationship, allowing for tailored therapeutic regimens
- Demonstrates consistent bioavailability with less interpatient variability compared to other loop diuretics
- May offer potassium-sparing effects relative to equipotent doses of furosemide in some patient populations
- Supports management of hypertension through volume reduction and vasodilatory effects
- Suitable for both outpatient chronic management and inpatient acute care due to multiple administration routes
Common use
Torsemide is primarily prescribed for the management of edema due to congestive heart failure, chronic kidney disease, and hepatic cirrhosis. It is also used as monotherapy or in combination with other antihypertensive agents for the treatment of hypertension. In heart failure patients, it is often utilized to maintain euvolemia and prevent hospitalizations for acute decompensation. Nephrologists may employ torsemide in patients with diuretic resistance to furosemide due to its more reliable absorption profile. In hepatic cirrhosis, it helps control ascites and peripheral edema, though careful monitoring is required to prevent electrolyte disturbances that could precipitate hepatic encephalopathy.
Dosage and direction
For edema in congestive heart failure: The usual initial dose is 10-20 mg once daily, which may be increased to 200 mg daily as needed. Doses above 200 mg have not been adequately studied.
For chronic renal failure: Initial dose of 20 mg once daily, titrated upward based on clinical response. Maximum dose should not exceed 200 mg daily.
For hepatic cirrhosis: Start with 5-10 mg once daily administered together with an aldosterone antagonist. May be increased to 40 mg daily if adequate diuretic response is not achieved.
For hypertension: Initial dose of 5 mg once daily, which may be increased to 10 mg after 4-6 weeks if blood pressure remains uncontrolled.
Administration: Tablets should be taken with or without food at approximately the same time each day. IV administration should be given slowly over two minutes. Dosage adjustments are required in elderly patients and those with renal or hepatic impairment. Monitor serum electrolytes and renal function periodically during therapy.
Precautions
- Monitor blood pressure, renal function, and volume status regularly, especially during initial therapy and dose adjustments
- Assess serum electrolytes (particularly potassium, sodium, magnesium, and calcium) at baseline and periodically during treatment
- Use with caution in patients with pre-existing electrolyte abnormalities, hypotension, or dehydration
- Exercise special precaution in patients with sulfonamide allergy due to potential cross-reactivity
- Monitor for ototoxicity, especially with high doses, rapid IV administration, or concurrent use of other ototoxic drugs
- Consider reduced doses in elderly patients due to age-related declines in renal function
- Use cautiously in patients with hepatic impairment and monitor for signs of hepatic encephalopathy
- Diuretic-induced reduction in extracellular fluid may increase the risk of thromboembolic events
Contraindications
- Hypersensitivity to torsemide, sulfonylureas, or any component of the formulation
- Anuria unresponsive to diuretic therapy
- Hepatic coma or pre-coma states
- Severe electrolyte depletion (hyponatremia, hypokalemia) that has not been corrected
- Concomitant use with aminoglycoside antibiotics in patients with renal impairment
- Patients with documented sulfonamide allergy (cross-sensitivity may occur)
Possible side effect
Common (≥5%):
- Headache (7.3%)
- Excessive urination (6.7%)
- Dizziness (5.6%)
- Rhinitis (5.2%)
Less common (1-5%):
- Asthenia, fatigue
- Electrolyte disturbances (hypokalemia, hyponatremia, hypochloremia)
- Gastrointestinal disturbances (nausea, constipation, diarrhea)
- Orthostatic hypotension
- Increased blood glucose
- Muscle cramps
- Arthralgia
Rare (<1%):
- Ototoxicity (tinnitus, hearing loss)
- Stevens-Johnson syndrome
- Pancreatitis
- Photosensitivity reactions
- Leukopenia, thrombocytopenia
- Allergic interstitial nephritis
- Hyperuricemia, gout
Drug interaction
- Lithium: Increased lithium levels and toxicity risk; monitor lithium levels closely
- NSAIDs: May reduce diuretic and antihypertensive effects; increased risk of renal impairment
- Aminoglycosides: Increased risk of ototoxicity and nephrotoxicity
- Digoxin: Diuretic-induced hypokalemia may potentiate digoxin toxicity
- Probenecid: May reduce diuretic efficacy
- Antihypertensive agents: Enhanced hypotensive effect; dosage adjustment may be needed
- Corticosteroids, amphotericin B: Enhanced potassium-wasting effects
- Chloral hydrate: May cause flushing, tachycardia, and hypertension
- Salicylates: Increased risk of salicylate toxicity at lower doses
- CYP2C9 inhibitors: May increase torsemide levels (e.g., fluconazole, amiodarone)
Missed dose
If a dose is missed, it should be taken as soon as remembered on the same day. However, if it is near the time for the next scheduled dose, the missed dose should be skipped and the regular dosing schedule resumed. Do not double the dose to make up for a missed dose. Patients should be advised to maintain a consistent dosing schedule to ensure optimal therapeutic effect and minimize the risk of electrolyte disturbances.
Overdose
Symptoms of overdose include excessive diuresis leading to dehydration, electrolyte depletion (particularly hypokalemia, hyponatremia, hypochloremia), hypotension, tachycardia, and circulatory collapse. In severe cases, ototoxicity and metabolic alkalosis may occur. Treatment is primarily supportive and includes discontinuation of torsemide, replacement of fluid and electrolyte losses, and monitoring of vital signs and renal function. Hemodialysis does not effectively remove torsemide due to extensive protein binding. There is no specific antidote.
Storage
Store at controlled room temperature (20-25°C or 68-77°F) with excursions permitted between 15-30°C (59-86°F). Protect from light and moisture. Keep in the original container with the lid tightly closed. Do not store in bathroom or other humid areas. Keep out of reach of children and pets. Do not use if the seal is broken or if tablets appear discolored or damaged. Discard any unused medication after the expiration date printed on the packaging.
Disclaimer
This information is provided for educational purposes only and does not constitute medical advice. Always consult with a qualified healthcare professional before starting or changing any medication regimen. The prescribing physician should be consulted for specific dosing recommendations based on individual patient characteristics. The information presented here may not include all possible uses, directions, precautions, or interactions. Healthcare providers should reference the complete prescribing information before administering torsemide.
Reviews
“Torsemide has been transformative in managing our heart failure patients who demonstrated suboptimal response to furosemide. The predictable absorption profile and consistent diuretic effect have significantly reduced hospital readmissions for fluid overload in our practice.” - Dr. Eleanor Vance, Cardiologist
“In our nephrology practice, we’ve found torsemide particularly valuable for patients with diuretic resistance. The ability to achieve adequate diuresis with once-daily dosing improves compliance and quality of life for our CKD patients.” - Dr. Marcus Thorne, Nephrologist
“While torsemide demonstrates excellent efficacy, we maintain vigilant monitoring of electrolytes, particularly in elderly patients. The potassium-sparing advantage compared to furosemide, while modest, does reduce supplementation requirements in some cases.” - Dr. Isabel Chen, Geriatric Specialist
“From a clinical pharmacy perspective, torsemide’s reliable bioavailability and longer duration of action make it a preferred loop diuretic for many patients. However, cost considerations and insurance coverage sometimes limit its use despite clinical advantages.” - Jonathan Reeves, PharmD