Torsem

Approved Indications:

• Edema associated with:
• Congestive heart failure
• Chronic renal failure
• Hepatic cirrhosis
• Nephrotic syndrome
• Hypertension (as monotherapy or in combination with other antihypertensive agents)

Clinically Accepted Off-Label Uses:

• Resistant Hypertension in patients unresponsive to thiazide diuretics
• Pulmonary Edema secondary to acute heart failure
• Hypercalcemia (in combination with IV fluids)

General Administration:

• Oral and intravenous routes available
• Should be taken at the same time daily, preferably in the morning
• Food does not significantly affect absorption

Adults:

• Edema due to CHF, renal or liver disease:
• Initial: 10–20 mg once daily
• Maintenance: Adjust dose every 3–4 days up to 200 mg/day based on response
• Hypertension:
• Initial: 2.5 mg once daily
• May be titrated up to 10 mg/day

Pediatric Use:

• Not well established; use only under specialist supervision

Elderly:

• Start at lower doses due to increased sensitivity
• Monitor renal function and electrolyte balance

Renal Impairment:

• May require higher doses in moderate to severe renal dysfunction
• Not significantly removed by dialysis

Hepatic Impairment:

• Use cautiously; risk of electrolyte imbalance and hepatic encephalopathy

IV Administration:

• Reserved for cases where oral administration is not feasible
• Equivalent dose to oral (bioavailability is high)
• Inject slowly over 2 minutes or administer as infusion

Torasemide is a loop diuretic that selectively inhibits the Na⁺/K⁺/2Cl⁻ symporter in the thick ascending limb of the loop of Henle. This inhibition reduces sodium and chloride reabsorption, leading to increased excretion of water, sodium, chloride, magnesium, and calcium. The resulting volume depletion reduces preload and afterload in heart failure, while the natriuretic effect contributes to blood pressure reduction in hypertensive patients.

• Absorption: Rapid oral absorption; bioavailability ~80–90%
• Onset of Action: Oral: ~1 hour; IV: ~10 minutes
• Peak Plasma Concentration: 1–2 hours after oral dose
• Distribution: Volume of distribution ~12–16 L
• Plasma Protein Binding: ~99%
• Metabolism: Hepatic (via CYP2C9) to inactive metabolites
• Elimination Half-life: ~3.5–4 hours (longer in renal/hepatic dysfunction)
• Excretion: ~80% via urine (20% unchanged); remainder via feces

Pregnancy:

• FDA Pregnancy Category B
• Animal studies do not show harm; human data lacking
• Use only if clearly needed and benefits outweigh risks

Lactation:

• Unknown if excreted in human milk; caution advised
• May suppress lactation due to diuretic effect
• Consider alternative therapy or advise against breastfeeding

• Primary Class: Loop Diuretic
• Subclass: Sulfonylurea-type loop diuretic (long-acting)
• Generation: Second-generation loop diuretic (more potent than furosemide)

• Hypersensitivity to torasemide or sulfonamides
• Anuria
• Hepatic coma or severe hepatic encephalopathy
• Severe electrolyte depletion (especially hypokalemia, hyponatremia)
• Hypotension or dehydration
• Pregnancy and lactation (relative, use with caution)

• Electrolyte imbalance: Monitor sodium, potassium, and magnesium levels closely
• Volume depletion: Risk of hypotension and renal dysfunction
• Renal function monitoring: Especially in patients with existing kidney disease or taking nephrotoxic drugs
• Hepatic impairment: Use cautiously; monitor for signs of encephalopathy
• Diabetes mellitus: May increase blood glucose
• Gout: Risk of hyperuricemia
• Hearing loss: Rare; monitor if used with ototoxic drugs
• Sulfonamide allergy: Cross-reactivity possible

Common (≥1%):

• Electrolyte imbalance: Hypokalemia, hyponatremia, hypomagnesemia
• Metabolic: Hyperuricemia, hyperglycemia
• Gastrointestinal: Nausea, diarrhea
• Cardiovascular: Hypotension, dizziness
• Neurological: Headache, fatigue

Serious (Rare):

• Renal failure
• Ototoxicity (at high doses)
• Thrombocytopenia
• Severe allergic reactions
• Hepatic encephalopathy (in cirrhotic patients)

Major Drug Interactions:

• ACE inhibitors / ARBs: Enhanced risk of hypotension and renal impairment
• Aminoglycosides / Vancomycin: Increased risk of ototoxicity
• Lithium: May increase lithium levels and toxicity
• NSAIDs: Decreased diuretic and antihypertensive effect
• Corticosteroids / Amphotericin B: Potentiated hypokalemia
• Antidiabetics: Reduced efficacy of insulin or oral agents
• Digitalis: Increased risk of digoxin toxicity due to hypokalemia

Metabolic Interactions:

• Metabolized by CYP2C9—interactions possible with CYP2C9 inhibitors or inducers

• 2022 ACC/AHA Heart Failure Guidelines continue to support torasemide over furosemide for better bioavailability and more predictable diuresis.
• Recent comparative studies suggest torasemide may be associated with lower hospital readmission rates in heart failure than furosemide.
• No new safety warnings from FDA or EMA as of mid-2025.

• Store at: 20°C to 25°C (68°F to 77°F)
• Allowable excursion: 15°C to 30°C
• Protection: Keep in a dry place, protected from light and moisture
• Do not freeze
• Keep out of reach of children
• IV formulation: Once opened, use immediately or store according to manufacturer's guidelines