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; up to the desired diuretic effect, the dose may be gradually increased by doubling.
-
Heart failure:
- 10–20 mg taken orally once daily at first.
- You can gradually raise the dose by doubling it up until you get the desired diuretic effect.
- 200 mg per day is the maximum dosage.
-
Hepatic cirrhosis:
- Initially, take 5 to 10 mg orally once daily.
- Up until the desired diuretic response is attained, the dose may be gradually raised by doubling dose.
- The maximum single dose that is advised is 40 mg.
- It should be administered along with an aldosterone antagonist or a potassium-saving diuretic, as noted.
Torsemide dose in the treatment of Hypertension:
- 5 mg used orally once daily at first;
- The dose may be increased to 10 mg once daily after 4-6 weeks if inadequate antihypertensive response.
Torsemide use in children:
The drug's effectiveness and safety in children are unknown.
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 intensify Allopurinol's harmful or toxic effects. Allopurinol's serum levels may rise in response to loop diuretics. In particular, Oxypurinol, an active metabolite of Allopurinol, may be increased in concentration by Loop Diuretics. |
|
Alpelisib |
May lower the serum level of CYP2C9 substrates (High risk with Inducers). |
|
Amikacin (Oral Inhalation) |
Loop Diuretics may increase Amikacin's nephrotoxic impact (Oral Inhalation). Loop Diuretics may increase Amikacin's ototoxic effects (Oral Inhalation). |
|
Aminoglycosides |
Aminoglycosides may have a worse or more toxic effect when used with loop diuretics. ototoxicity and nephrotoxicity in particular. |
|
Amphetamines |
May lessen the effectiveness of antihypertensive agents. |
|
Angiotensin-Converting Enzyme Inhibitors |
Angiotensin-Converting Enzyme Inhibitors' hypotensive effects may be strengthened by loop diuretics. Angiotensin-Converting Enzyme Inhibitors' nephrotoxic effects may be increased by loop diuretics. |
|
Antidiabetic Agents |
The therapeutic benefit of anti-diabetic agents may be reduced by hyperglycemia-associated agents. |
|
Antipsychotic Agents (Second Generation [Atypical]) |
Antipsychotic drugs' hypotensive effects may be enhanced by blood pressure-lowering medications (Second Generation [Atypical]). |
|
Barbiturates |
The hypotensive effects of blood pressure-lowering medications may be strengthened. |
|
Benperidol |
The hypotensive effects of blood pressure-lowering medications may be strengthened. |
|
Beta2-Agonists |
May intensify Loop Diuretics' hypokalemic impact. |
|
Bilastine |
The QTc-prolonging effects of loop diuretics may be enhanced by 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 |
Cardiac Glycosides may have a worse or more toxic effect when used with loop diuretics. Particularly, the hypokalemic and hypomagnesemic impact of loop diuretics may worsen cardiac glycoside toxicity. |
|
Cefazedone |
May intensify Loop Diuretics' nephrotoxic effects. |
|
Cefotiam |
Loop Diuretics may intensify Ceftiam's nephrotoxic effects. |
|
Cefpirome |
Loop Diuretics may enhance the nephrotoxic effect of Cefpirome. |
|
Ceftizoxime |
Loop Diuretics may enhance the nephrotoxic effect of Ceftizoxime. |
|
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 lower the serum level of CYP2C9 substrates (High risk with Inducers). |
|
CYP2C9 Inhibitors (Moderate) |
Torsemide serum concentration can rise. |
|
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 |
The hypotensive impact of DULoxetine may be enhanced by blood pressure lowering medications. |
|
Eltrombopag |
May raise the level of OATP1B1/1B3 (SLCO1B1/1B3) Substrates in the serum. |
|
Empagliflozin |
May enhance the hypotensive effect of Loop Diuretics. |
|
Fosphenytoin |
May diminish the diuretic effect of Loop Diuretics. |
|
Gemfibrozil |
May raise the level of OATP1B1/1B3 (SLCO1B1/1B3) Substrates in the serum. |
|
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 intensify Loop Diuretics' harmful or hazardous effects. In particular, there may be an elevated risk for intravascular volume depletion. |
|
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 lower the level of lithium in the blood. Loop Diuretics may raise the level of lithium in the blood. |
|
Lormetazepam |
The hypotensive effects of blood pressure-lowering medications may be strengthened. |
|
Lumacaftor |
May lower the serum level of CYP2C9 substrates (High Risk with Inhibitors or Inducers). The serum concentration of CYP2C9 Substrates may rise when taking lumacaftor (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 |
The hypotensive effects of blood pressure-lowering medications may be strengthened. |
|
Nitroprusside |
Nitroprusside's hypotensive impact may be strengthened by blood pressure-lowering medications. |
|
Opioid Agonists |
Could make diuretics' harmful or toxic effects worse. Opioid antagonists may reduce diuretics' therapeutic benefit. |
|
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. |
|
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 lower the serum level of CYP2C9 substrates (High risk with Inducers). |
|
RisperiDONE |
Loop Diuretics may intensify RisperiDONE's harmful or hazardous effects. |
|
Salicylates |
May lessen Loop Diuretics' diuretic effects. The content of salicylates in the serum |
|
Teriflunomide |
May rise when using loop diuretics. |
|
Tobramycin (Oral Inhalation) |
May raise the level of OATP1B1/1B3 (SLCO1B1/1B3) Substrates in the serum. |
|
Topiramate |
Loop Diuretics may increase Tobramycin's nephrotoxic effects (Oral Inhalation). Loop Diuretics may increase Tobramycin's ototoxic effects (Oral Inhalation). |
|
Warfarin |
Topiramate's effect on hypokalemia may be enhanced by loop diuretics. |
|
Xipamide |
May intensify Loop Diuretics' harmful or hazardous effects. Particularly, there may be a higher chance of hypovolemia, electrolyte imbalances, and prerenal azotemia. |
|
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 lower the serum level of CYP2C9 substrates (High risk with Inducers). Management: When possible, look for CYP2C9 substrate substitutes. If concurrent therapy cannot be avoided, pay special attention to the substrate's clinical consequences (particularly therapeutic effects). |
|
Dofetilide |
Loop Diuretics may increase Dofetilide's ability to extend QTc. Management: When dofetilide is taken with loop diuretics, serum potassium and magnesium levels should be continuously monitored. The need for therapy change may arise. |
|
Enzalutamide |
May lower the serum level of CYP2C9 substrates (High risk with Inducers). Treatment: Enzalutamide should not be used concurrently with CYP2C9 substrates that have a limited therapeutic index. Enzalutamide use, like with the use of any other CYP2C9 substrate, should be done with caution and under close observation. |
|
Foscarnet |
Loop Diuretics may raise the level of foscarnet in the blood. |
|
Methotrexate |
May reduce Loop Diuretics' therapeutic efficacy. Loop diuretics may raise the level of methotrexate in the serum. Loop Diuretics' serum levels may be raised by methotrexate. Management involves monitoring for elevated methotrexate and/or loop diuretic levels/toxicity with concurrent use of these drugs as well as for diminished loop diuretic therapeutic effects. It could be essential to reduce the dosage of loop diuretics or methotrexate. |
|
MiFEPRIStone |
May elevate CYP2C9 substrates' serum levels (High risk with Inhibitors). Management: During and for two weeks after mifepristone treatment, use CYP2C9 substrates at the lowest dose advised and keep a close eye out for any negative effects. |
|
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 raise the level of OATP1B1/1B3 (SLCO1B1/1B3) Substrates in the serum. |
|
Risk Factor X (Avoid combination) |
|
|
Bromperidol |
The hypotensive impact of bromperidol may be enhanced by blood pressure lowering medications. Blood Pressure Lowering Agents' hypotensive effects may be lessened by bromperidol. |
|
Desmopressin |
Desmopressin's hyponatremic impact may be increased by loop diuretics. |
|
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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