torsemide

Torsemide is a medication used to reduce fluid retention and swelling (edema) associated with conditions such as heart failure, kidney disease, and liver disease (cirrhosis). Torsemide is also used to manage high blood pressure (hypertension), however, it is not recommended for the initial treatment of hypertension.

Torsemide is a type of diuretic medication that reduces fluid collection in the body by increasing urine output. Torsemide inhibits the reabsorption of water and sodium in the kidneys, increasing their excretion in the urine. Torsemide also increases the urinary excretion of other minerals including chloride, magnesium, calcium, and potassium.

Torsemide works by interfering with the reabsorption process in the thick ascending portion of the loop of Henle. Kidneys are made up of filtering units known as nephrons, and the loop of Henle is a U-shaped part of the nephron that is responsible for fluid reabsorption.

• Do not use torsemide in the following conditions:
  • Known hypersensitivity to torsemide or any of its components
  • Absence of urine production (anuria)
  • Coma due to liver disease (hepatic coma)
• Excessive fluid loss from diuresis can lead to dehydration, reduced blood volume (hypovolemia), low blood pressure (hypertension), and impairment of kidney function. Monitor the patient’s volume status and kidney function regularly while on torsemide therapy.
• Risk of kidney failure from torsemide use is higher in:
  • Salt-depleted patients
  • Patients on hypertension medications (renin-angiotensin aldosterone inhibitors)
  • Simultaneous use of other drugs that are toxic to the kidneys
• Torsemide may decrease electrolyte levels and increase uric acid and glucose levels in the blood. Monitor serum electrolyte, uric acid, and glucose levels regularly. 
• Use with caution in patients with diabetes mellitus. Torsemide use may further increase glucose levels.
• Use with caution in patients with electrolyte imbalances. Torsemide may worsen the condition.
• Use with caution in patients with liver cirrhosis and associated abdominal fluid collection (ascites). Electrolyte and acid/base imbalances may lead to brain damage (hepatic encephalopathy).
• Torsemide may be toxic to the ear (ototoxic). The risk increases with:
  • Higher than recommended doses
  • Severe kidney impairment
  • Low protein levels in blood (hypoproteinemia)

Common side effects of torsemide include:

• Excessive urination (polyuria) and related symptoms including:
  • Dehydration
  • Low blood pressure (hypotension)
  • Decrease in blood volume (hypovolemia)
  • Impairment of kidney function
• Electrolyte imbalances including:
  • Low potassium (hypokalemia)
  • Low sodium (hyponatremia)
  • Low magnesium (hypomagnesemia)
  • Low calcium (hypocalcemia)
  • Alkalinity due to low chloride levels (hypochloremic alkalosis)
• Headache
• Dizziness
• Nasal inflammation (rhinitis)
• Cough
• Nausea
• Constipation
• Diarrhea
• Indigestion (dyspepsia)
• Nervousness
• Insomnia

Less common side effects of torsemide include

• Excessive uric acid in blood (hyperuricemia)
• Gout (rare)
• High blood glucose (hyperglycemia)
• Increase in serum cholesterol
• Increase in serum triglycerides
• Ringing in the ears (tinnitus)
• Hearing loss
• Visual impairment
• Confusion
• Abnormal skin sensation (paresthesia)
• Pancreatitis
• Abdominal pain
• Loss of appetite (anorexia)
• Increase in liver enzymes (transaminases and gamma-glutamyl transferase)
• Thiamine (vitamin B1) deficiency
• Blood disorders including:
  • Low red blood cell count (anemia)
  • Low blood count of leukocyte immune cells (leukopenia)
  • Low platelet levels (thrombocytopenia)
• Skin hypersensitivity reactions including:
  • Itching (pruritus)
  • Photosensitivity reaction
  • Stevens-Johnson syndrome
  • Toxic epidermal necrolysis
• Acute urinary retention
• Kidney injury

This is not a complete list of all side effects or adverse reactions that may occur from the use of this drug. Call your doctor for medical advice about serious side effects or adverse reactions. You may also report side effects or health problems to the FDA at 1-800-FDA-1088.

Tablet

• 5mg (generic)
• 10mg (generic)
• 20mg (Soaanz, generic)
• 60mg (Soaanz, generic)
• 100mg

Adult:

Edema

Indicated for treatment of edema associated with heart failure or renal disease

• 10-20 mg orally once a day initially; may increase dose by doubling until desired diuretic effect is achieved
• Doses over 200 mg have not been adequately studied

Hepatic Cirrhosis

Indicated for treatment of edema associated with hepatic disease

• 5-10 mg orally once a day initially with aldosterone antagonist or potassium-sparing diuretic; may increase dose by doubling until desired diuretic effect achieved
• Doses over 40 mg have not been adequately studied

Hypertension

• 2.5-5 mg/day orally initially; increased to 10 mg/day orally in 4-6 weeks as needed
• Consider adding another antihypertensive agent if 10-mg dose is insufficient

Dosage Modifications

Renal impairment

• No dosage adjustments provided in prescribing information
• Higher doses may be required to achieve diuretic effect

Hepatic impairment

• No dosage adjustments provided in prescribing information
• Use with caution
• Contraindicated in hepatic coma

Dosing Considerations

• Use for fluid retention refractory to thiazides or with impaired renal function

Overdose management

• Normal saline may be used for volume replacement
• Dopamine or norepinephrine may be used to treat hypotension
• If dysrhythmia due to decreased potassium or magnesium is suspected, replace aggressively
• Discontinue treatment if no symptoms are apparent after 6 hours

Pediatric:

• Safety and efficacy not established

• Overdose of torsemide can cause excessive fluid and mineral loss, resulting in
  • dehydration,
  • hypovolemia,
  • blood thickening (hemoconcentration),
  • hypotension, and decrease in electrolyte levels.
• Overdose of torsemide is treated with intravenous fluids and electrolyte replacement.

Inform your doctor of all medications you are currently taking, who can advise you on any possible drug interactions. Never begin taking, suddenly discontinue, or change the dosage of any medication without your doctor’s recommendation.

• Torsemide has no known severe interactions with other drugs.
• Serious interactions of torsemide include:
  • amikacin
  • gentamicin
  • ivosidenib
  • lofexidine
  • neomycin PO
  • paromomycin
  • squill
  • streptomycin
  • tobramycin
• Torsemide has moderate interactions with at least 155 different drugs.
• Torsemide has mild interactions with at least 71 different drugs.

The drug interactions listed above are not all of the possible interactions or adverse effects. For more information on drug interactions, visit the RxList Drug Interaction Checker.

It is important to always tell your doctor, pharmacist, or health care provider of all prescription and over-the-counter medications you use, as well as the dosage for each, and keep a list of the information. Check with your doctor or health care provider if you have any questions about the medication.

• There are no data on the use of torsemide during pregnancy and risk of birth defects or miscarriage.
• It is not known if torsemide is present in breast milk or its effects on the breastfed infant. Diuretics, including torsemide, can suppress lactation.

• Take torsemide exactly as prescribed.
• Store torsemide safely out of reach of children.
• In case of overdose, increase fluid and electrolyte intake and seek medical help.
• Consult with your physician before taking non-steroidal anti-inflammatory drugs (NSAIDs) while on torsemide therapy.
• You may feel lightheaded, especially in the initial days of torsemide therapy. Report to your physician if there is lightheadedness, and in case fainting occurs, discontinue torsemide and consult your physician.
• Drink adequate fluids while on torsemide. Low fluid intake, excessive sweating, vomiting, or diarrhea can all lead to lightheadedness and fainting. Seek medical help if required.