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Torsemide (torasemide): Drug information

Torsemide (torasemide): Drug information
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For additional information see "Torsemide (torasemide): Patient drug information" and "Torsemide (torasemide): Pediatric drug information"

For abbreviations, symbols, and age group definitions show table
Brand Names: US
  • Soaanz
Pharmacologic Category
  • Antihypertensive;
  • Diuretic, Loop
Dosing: Adult

Note: Loop diuretic approximate oral dose equivalency for patients with normal renal function: Torsemide 10 to 20 mg = bumetanide 1 mg = furosemide 40 mg (Ref).

Edema or volume overload

Edema or volume overload (alternative agent):

Note: Consider for use as a replacement if initial therapy with furosemide is not effective (eg, poor absorption of furosemide). Although loop diuretics are not recommended for initial management of hypertension, they may be used when edema persists despite use of a thiazide diuretic or instead of a thiazide diuretic in patients with severely reduced kidney function and edema (Ref). When used as a replacement for another loop diuretic, refer to the equivalencies above.

Naive to loop diuretics

Oral: Initial: 10 to 20 mg once daily; double the dose as needed (rather than administer the same dose more frequently) until diuresis occurs. The maximum effective dose varies by population; higher-than-usual doses may be required for patients with nephrotic syndrome or kidney failure; maximum effective single dose: 50 to 100 mg; maximum recommended total daily dose: 200 mg in 2 divided doses to minimize risk of ototoxicity (Ref).

Hypertension

Hypertension (alternative agent):

Note: A loop diuretic is preferred over other diuretics in patients with symptomatic heart failure or advanced chronic kidney disease, especially when hypertension is associated with edema (Ref).

Oral: Initial: 5 mg once daily; may increase to 10 mg once daily after 4 to 6 weeks if inadequate antihypertensive response (Ref).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Adult

The renal dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason A. Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.

Altered kidney function:

IV, Oral:

eGFR >30 mL/minute/1.73 m2: No dosage adjustment necessary.

eGFR ≤30 mL/minute/1.73 m2: Higher doses may be required to achieve desired diuretic response due to decreased secretion into the tubular fluid. However, single doses >50 to 100 mg are unlikely to result in additional diuretic effect (Ref).

Hemodialysis, intermittent (thrice weekly): Not dialyzable (Ref):

IV, Oral:

Anuric patients: There is no expected clinical benefit; use not recommended (Ref).

Patients with residual kidney function: Dose as per eGFR ≤30 mL/minute/1.73 m2 (Ref).

Peritoneal dialysis: Not dialyzable (highly protein bound) (Ref):

IV, Oral:

Anuric patients: There is no expected clinical benefit; use not recommended (Ref).

Patients with residual kidney function: Dose as per eGFR ≤30 mL/minute/1.73 m2 (Ref).

CRRT:

Note: Drug clearance is dependent on the effluent flow rate, filter type, and method of renal replacement. Recommendations are based on high-flux dialyzers and effluent flow rates of 20 to 25 mL/kg/hour (or ~1,500 to 3,000 mL/hour) unless otherwise noted.

IV, Oral: In general, use not recommended; fluid management can be more effectively managed using CRRT ultrafiltration (Ref).

PIRRT (eg, sustained, low-efficiency diafiltration):

Note: Drug clearance is dependent on the effluent flow rate, filter type, and method of renal replacement. Close monitoring of response and adverse reactions (eg, ototoxicity) due to drug accumulation is important.

IV, Oral:

Anuric patients: There is no expected clinical benefit; use not recommended (Ref).

Patients with residual kidney function: Dose as per eGFR ≤30 mL/minute/1.73 m2 (Ref).

Dosing: Liver Impairment: Adult

There are no dosage adjustments provided in the manufacturer’s labeling; use with caution. Use is contraindicated in hepatic coma.

Dosing: Older Adult

Refer to adult dosing.

Adverse Reactions (Significant): Considerations
Acute kidney injury

Loop diuretics, including torsemide, may lead to acute kidney injury (AKI) due to fluid loss (Ref). Torsemide may be associated with less risk of AKI compared to furosemide (Ref).

Mechanism: Dose-related; related to the pharmacologic action (ie, volume depletion) (Ref).

Risk factors:

• Excessive doses (Ref)

• Concurrent administration of nephrotoxic agents (Ref)

• Older adults (Ref)

• Preexisting volume depletion (Ref)

• Reduced blood flow to the kidney or depletion of effective blood volume (eg, bilateral renal artery stenosis, cirrhosis, nephrotic syndrome, heart failure) (Ref)

Fluid/electrolyte loss

Loop diuretics, including torsemide, may lead to profound diuresis (especially if given in excessive amounts), resulting in hypovolemia and electrolyte loss. Electrolyte disturbances (eg, hypocalcemia, hypokalemia, hypomagnesemia) may predispose a patient to serious cardiac arrhythmias. Torsemide may be associated with less risk of hypokalemia than furosemide (Ref).

Mechanism: Dose-related; related to the pharmacologic action (Ref).

Risk factors:

• Excessive doses with initiation or dose adjustment (Ref)

• Reduced dietary fluid and/or electrolyte intake (Ref)

• Concurrent illness leading to excessive fluid loss (eg, diarrhea, vomiting) (Ref)

• Concomitant administration of an additional diuretic (Ref)

• Very high or very restricted dietary sodium (Ref)

Hypersensitivity reactions (delayed)

Delayed hypersensitivity reactions, including Stevens-Johnson syndrome and toxic epidermal necrolysis, have been reported. A photosensitive lichenoid eruption has also been reported (Ref).

Mechanism: Delayed hypersensitivity reactions: Non–dose-related; immunologic (ie, involving a T-cell mediated drug-specific immune response) (Ref).

Onset: Delayed hypersensitivity reactions: Varied; typically occurs days to 8 weeks after drug exposure (Ref) but may occur more rapidly (usually within 1 to 4 days) upon reexposure (Ref).

Risk factors:

• Cross-reactivity: Cross-reactivity between antibiotic sulfonamides and nonantibiotic sulfonamides (such as torsemide) may not occur, or at the very least this potential is extremely low (Ref). Cross-reactivity due to antibody production (anaphylaxis) is unlikely to occur with antibiotic sulfonamides and nonantibiotic sulfonamides (Ref). There is limited published information regarding cross-reactivity between torsemide and other sulfonamide loop diuretics (Ref).

Ototoxicity

Loop diuretics, including torsemide, have been associated with hearing loss (deafness) and tinnitus, which are generally reversible (lasting from 30 minutes to 24 hours after administration) (Ref).

Mechanism: Dose-related; related to the pharmacologic action (ie, inhibition of a secretory isoform of the Na-K-2Cl co-transporter in the inner ear and impacts on ionic composition of cochlear fluids) (Ref).

Risk factors:

• Concurrent kidney disease (Ref)

• Excessive doses (Ref)

• Concurrent use of other ototoxic agents (eg, aminoglycosides) can lead to ototoxicity at lower doses (Ref)

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.

1% to 10%: Renal: Polyuria (7%)

Frequency not defined: Endocrine & metabolic: Hypokalemia, increased serum cholesterol, increased serum glucose, increased serum triglycerides

Postmarketing:

Dermatologic: Lichenoid eruption (Byrd 1997), pruritus, skin photosensitivity, Stevens-Johnson syndrome, toxic epidermal necrolysis (Reddy 2022)

Endocrine & metabolic: Hyperuricemia (Hagos 2007), vitamin B deficiency (thiamine)

Gastrointestinal: Abdominal pain, anorexia, pancreatitis (Juang 2006)

Genitourinary: Acute urinary retention

Hematologic & oncologic: Anemia, leukopenia, thrombocytopenia

Hepatic: Increased gamma-glutamyl transferase, increased serum transaminases

Nervous system: Confusion, paresthesia

Neuromuscular & skeletal: Gout (Choi 2005)

Ophthalmic: Visual impairment

Otic: Hearing loss (Bagshaw 2007), tinnitus (Bagshaw 2007)

Renal: Acute kidney injury (Liu 2021)

Contraindications

Hypersensitivity to torsemide or any component of the formulation; anuria; hepatic coma.

Warnings/Precautions

Concerns related to adverse effects:

• Hyperuricemia: Asymptomatic hyperuricemia may occur; gout may be precipitated (rarely).

• Sulfonamide (“sulfa”) allergy: The FDA-approved product labeling for many medications containing a sulfonamide chemical group includes a broad contraindication in patients with a prior allergic reaction to sulfonamides. There is a potential for cross-reactivity between members of a specific class (eg, 2 antibiotic sulfonamides). However, concerns for cross-reactivity have previously extended to all compounds containing the sulfonamide structure (SO2NH2). An expanded understanding of allergic mechanisms indicates cross-reactivity between antibiotic sulfonamides and nonantibiotic sulfonamides may not occur or at the very least this potential is extremely low (Brackett 2004; Johnson 2005; Slatore 2004; Tornero 2004). In particular, mechanisms of cross-reaction due to antibody production (anaphylaxis) are unlikely to occur with nonantibiotic sulfonamides. T-cell-mediated (type IV) reactions (eg, maculopapular rash) are not well understood and it is not possible to completely exclude this potential based on current insights. In cases where prior reactions were severe (Stevens-Johnson syndrome/TEN), some clinicians choose to avoid exposure to these classes.

Disease-related concerns:

• Adrenal insufficiency: Avoid use of diuretics for treatment of elevated blood pressure in patients with primary adrenal insufficiency (Addison disease). Adjustment of glucocorticoid/mineralocorticoid therapy and/or use of other antihypertensive agents is preferred to treat hypertension (Bornstein 2016; Inder 2015).

• Bariatric surgery: Dehydration: Avoid diuretics in the immediate postoperative period after bariatric surgery; electrolyte disturbances and dehydration may occur. Diuretics may be resumed, if indicated, once oral fluid intake goals are met (Ziegler 2009).

• Diabetes: Use with caution in patients with diabetes; increased blood glucose levels and hyperglycemia may occur. Monitor blood glucose periodically.

• Hepatic impairment: Use with caution in patients with hepatic impairment; in patients with cirrhosis, avoid electrolyte and acid/base imbalances that may lead to hepatic encephalopathy. Administration with an aldosterone antagonist or potassium-sparing diuretic may provide additional diuretic efficacy and maintain normokalemia in patients with hepatic disease.

Special populations:

• Surgical patients: If given the morning of surgery, torsemide may render the patient volume depleted and blood pressure may be labile during general anesthesia.

Other warnings and precautions:

• Diuretic resistance: For some patients, despite high doses of loop diuretic, an adequate diuretic response cannot be attained. Diuretic resistance may be overcome by intravenous rather than oral administration, the use of two diuretics together (eg, a loop diuretic in combination with a thiazide diuretic). When multiple diuretics are used, serum electrolytes need to be monitored even more closely (ACC [Hollenberg 2019]).

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Tablet, Oral:

Soaanz: 20 mg, 40 mg, 60 mg

Generic: 5 mg, 10 mg, 20 mg, 100 mg

Generic Equivalent Available: US

Yes

Pricing: US

Tablets (Soaanz Oral)

20 mg (per each): $10.48

40 mg (per each): $11.80

60 mg (per each): $10.92

Tablets (Torsemide Oral)

5 mg (per each): $0.63

10 mg (per each): $0.70 - $0.72

20 mg (per each): $0.29 - $0.82

100 mg (per each): $0.81 - $3.04

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Administration: Adult

Oral: May administer with or without food.

Administration: Pediatric

Oral: Administer without regard to meals.

Use: Labeled Indications

Edema or volume overload: Treatment of edema.

Hypertension: Management of hypertension.

Medication Safety Issues
Sound-alike/look-alike issues:

Torsemide may be confused with furosemide

Demadex may be confused with Denorex

Older Adult: High-Risk Medication:

Beers Criteria: Diuretics are identified in the Beers Criteria as potentially inappropriate medications to be used with caution in patients 65 years and older due to the potential to cause or exacerbate syndrome of inappropriate antidiuretic hormone secretion (SIADH) or hyponatremia; monitor sodium concentration closely when initiating or adjusting the dose in older adults (Beers Criteria [AGS 2023]).

Metabolism/Transport Effects

Substrate of CYP2C8 (Minor), CYP2C9 (Minor), OAT1/3, OATP1B1/1B3; Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential;

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.

Ajmaline: Sulfonamides may increase adverse/toxic effects of Ajmaline. Specifically, the risk for cholestasis may be increased. Risk C: Monitor

Alfuzosin: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Allopurinol: Loop Diuretics may increase adverse/toxic effects of Allopurinol. Loop Diuretics may increase serum concentration of Allopurinol. Specifically, Loop Diuretics may increase the concentration of Oxypurinol, an active metabolite of Allopurinol. Risk C: Monitor

Amifostine: Blood Pressure Lowering Agents may increase hypotensive effects of Amifostine. Management: When used at chemotherapy doses, hold blood pressure lowering medications for 24 hours before amifostine administration. If blood pressure lowering therapy cannot be held, do not administer amifostine. Use caution with radiotherapy doses of amifostine. Risk D: Consider Therapy Modification

Amikacin Liposome (Oral Inhalation): Loop Diuretics may increase nephrotoxic effects of Amikacin Liposome (Oral Inhalation). Loop Diuretics may increase ototoxic effects of Amikacin Liposome (Oral Inhalation). Risk C: Monitor

Aminoglycosides: Loop Diuretics may increase adverse/toxic effects of Aminoglycosides. Specifically, nephrotoxicity and ototoxicity. Risk C: Monitor

Aminolevulinic Acid (Systemic): Photosensitizing Agents may increase photosensitizing effects of Aminolevulinic Acid (Systemic). Risk X: Avoid

Aminolevulinic Acid (Topical): Photosensitizing Agents may increase photosensitizing effects of Aminolevulinic Acid (Topical). Risk C: Monitor

Amiodarone: May increase hypotensive effects of Torsemide. Amiodarone may increase serum concentration of Torsemide. Risk C: Monitor

Amphetamines: May decrease antihypertensive effects of Antihypertensive Agents. Risk C: Monitor

Angiotensin II Receptor Blockers: Loop Diuretics may increase hypotensive effects of Angiotensin II Receptor Blockers. Loop Diuretics may increase nephrotoxic effects of Angiotensin II Receptor Blockers. Risk C: Monitor

Angiotensin-Converting Enzyme Inhibitors: Loop Diuretics may increase hypotensive effects of Angiotensin-Converting Enzyme Inhibitors. Loop Diuretics may increase nephrotoxic effects of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor

Antidiabetic Agents: Hyperglycemia-Associated Agents may decrease therapeutic effects of Antidiabetic Agents. Risk C: Monitor

Antihypertensive Agents: Loop Diuretics may increase hypotensive effects of Antihypertensive Agents. Risk C: Monitor

Antipsychotic Agents (Second Generation [Atypical]): Blood Pressure Lowering Agents may increase hypotensive effects of Antipsychotic Agents (Second Generation [Atypical]). Risk C: Monitor

Arginine: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Arsenic Trioxide: Loop Diuretics may increase QTc-prolonging effects of Arsenic Trioxide. Loop Diuretics may increase hypotensive effects of Arsenic Trioxide. Management: When possible, avoid concurrent use of arsenic trioxide with drugs that can cause electrolyte abnormalities, such as the loop diuretics. Risk D: Consider Therapy Modification

Barbiturates: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Benperidol: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Beta2-Agonists: May increase hypokalemic effects of Loop Diuretics. Risk C: Monitor

Bilastine: Loop Diuretics may increase QTc-prolonging effects of Bilastine. Risk C: Monitor

Bile Acid Sequestrants: May decrease absorption of Loop Diuretics. Risk C: Monitor

Brigatinib: May decrease antihypertensive effects of Antihypertensive Agents. Brigatinib may increase bradycardic effects of Antihypertensive Agents. Risk C: Monitor

Brimonidine (Topical): May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Bromperidol: May decrease hypotensive effects of Blood Pressure Lowering Agents. Blood Pressure Lowering Agents may increase hypotensive effects of Bromperidol. Risk X: Avoid

Canagliflozin: May increase hypotensive effects of Loop Diuretics. Risk C: Monitor

Cardiac Glycosides: Loop Diuretics may increase adverse/toxic effects of Cardiac Glycosides. Specifically, cardiac glycoside toxicity may be enhanced by the hypokalemic and hypomagnesemic effect of loop diuretics. Risk C: Monitor

Cefazedone: May increase nephrotoxic effects of Loop Diuretics. Risk C: Monitor

Cefotiam: Loop Diuretics may increase nephrotoxic effects of Cefotiam. Risk C: Monitor

Cefpirome: Loop Diuretics may increase nephrotoxic effects of Cefpirome. Risk C: Monitor

Ceftizoxime: Loop Diuretics may increase nephrotoxic effects of Ceftizoxime. Risk C: Monitor

Cephaloridine: Loop Diuretics may increase nephrotoxic effects of Cephaloridine. Loop Diuretics may increase serum concentration of Cephaloridine. Risk X: Avoid

Cephalothin: Loop Diuretics may increase nephrotoxic effects of Cephalothin. Risk C: Monitor

Cephradine: May increase nephrotoxic effects of Loop Diuretics. Risk C: Monitor

CISplatin: Loop Diuretics may increase ototoxic effects of CISplatin. Loop Diuretics may increase nephrotoxic effects of CISplatin. Risk C: Monitor

Corticosteroids (Systemic): May increase hypokalemic effects of Loop Diuretics. Risk C: Monitor

CycloSPORINE (Systemic): May increase adverse/toxic effects of Loop Diuretics. Specifically, the risk for hyperuricemia and gout may be increased. Risk C: Monitor

CYP2C9 Inducers (Moderate): May decrease serum concentration of Torsemide. Risk C: Monitor

CYP2C9 Inhibitors (Moderate): May increase serum concentration of Torsemide. Risk C: Monitor

Desmopressin: May increase hyponatremic effects of Loop Diuretics. Risk X: Avoid

Dexmethylphenidate: May decrease therapeutic effects of Antihypertensive Agents. Risk C: Monitor

Diacerein: May increase therapeutic effects of Diuretics. Specifically, the risk for dehydration or hypokalemia may be increased. Risk C: Monitor

Diazoxide: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Dichlorphenamide: Loop Diuretics may increase hypokalemic effects of Dichlorphenamide. Risk C: Monitor

Dofetilide: Loop Diuretics may increase QTc-prolonging effects of Dofetilide. Management: Monitor serum potassium and magnesium more closely when dofetilide is combined with loop diuretics. Electrolyte replacements will likely be required to maintain potassium and magnesium serum concentrations. Risk D: Consider Therapy Modification

DULoxetine: Blood Pressure Lowering Agents may increase hypotensive effects of DULoxetine. Risk C: Monitor

Empagliflozin: May increase hypotensive effects of Loop Diuretics. Risk C: Monitor

EPINEPHrine (Systemic): Diuretics may increase arrhythmogenic effects of EPINEPHrine (Systemic). Diuretics may decrease vasopressor effects of EPINEPHrine (Systemic). Risk C: Monitor

Fexinidazole: May increase serum concentration of OAT1/3 Substrates (Clinically Relevant). Management: Avoid use of fexinidazole with OAT1/3 substrates when possible. If combined, monitor for increased OAT1/3 substrate toxicities. Risk D: Consider Therapy Modification

Flunarizine: May increase therapeutic effects of Antihypertensive Agents. Risk C: Monitor

Foscarnet: Loop Diuretics may increase serum concentration of Foscarnet. Management: When diuretics are indicated during foscarnet treatment, thiazides are recommended over loop diuretics. If patients receive loop diuretics during foscarnet treatment, monitor closely for evidence of foscarnet toxicity. Risk D: Consider Therapy Modification

Fosphenytoin-Phenytoin: Torsemide may increase adverse/toxic effects of Fosphenytoin-Phenytoin. Risk C: Monitor

Herbal Products with Blood Pressure Increasing Effects: May decrease antihypertensive effects of Antihypertensive Agents. Risk C: Monitor

Herbal Products with Blood Pressure Lowering Effects: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Hypotension-Associated Agents: Blood Pressure Lowering Agents may increase hypotensive effects of Hypotension-Associated Agents. Risk C: Monitor

Iloperidone: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Immune Globulin: Loop Diuretics may increase thrombogenic effects of Immune Globulin. Risk C: Monitor

Indoramin: May increase hypotensive effects of Antihypertensive Agents. Risk C: Monitor

Iodinated Contrast Agents: Loop Diuretics may increase nephrotoxic effects of Iodinated Contrast Agents. Risk C: Monitor

Ipragliflozin: May increase adverse/toxic effects of Loop Diuretics. Specifically, the risk for intravascular volume depletion may be increased. Risk C: Monitor

Isocarboxazid: May increase hypotensive effects of Diuretics. Risk X: Avoid

Ivabradine: Loop Diuretics may increase arrhythmogenic effects of Ivabradine. Risk C: Monitor

Leflunomide: May increase serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk C: Monitor

Levodopa-Foslevodopa: Blood Pressure Lowering Agents may increase hypotensive effects of Levodopa-Foslevodopa. Risk C: Monitor

Levosulpiride: Loop Diuretics may increase adverse/toxic effects of Levosulpiride. Risk X: Avoid

Licorice: May increase hypokalemic effects of Loop Diuretics. Risk C: Monitor

Lithium: Loop Diuretics may decrease serum concentration of Lithium. Loop Diuretics may increase serum concentration of Lithium. Risk C: Monitor

Loop Diuretics: May increase hypotensive effects of Antihypertensive Agents. Risk C: Monitor

Lormetazepam: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Mecamylamine: Sulfonamides may increase adverse/toxic effects of Mecamylamine. Risk X: Avoid

Metergoline: May decrease antihypertensive effects of Blood Pressure Lowering Agents. Blood Pressure Lowering Agents may increase orthostatic hypotensive effects of Metergoline. Risk C: Monitor

Methotrexate: May decrease therapeutic effects of Loop Diuretics. Loop Diuretics may increase serum concentration of Methotrexate. Methotrexate may increase serum concentration of Loop Diuretics. Risk C: Monitor

Methoxsalen (Systemic): Photosensitizing Agents may increase photosensitizing effects of Methoxsalen (Systemic). Risk C: Monitor

Methylphenidate: May decrease antihypertensive effects of Antihypertensive Agents. Risk C: Monitor

Molsidomine: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Naftopidil: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Netilmicin (Ophthalmic): Loop Diuretics may increase nephrotoxic effects of Netilmicin (Ophthalmic). Risk X: Avoid

Neuromuscular-Blocking Agents: Loop Diuretics may decrease neuromuscular-blocking effects of Neuromuscular-Blocking Agents. Loop Diuretics may increase neuromuscular-blocking effects of Neuromuscular-Blocking Agents. Risk C: Monitor

Nicergoline: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Nicorandil: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Nitisinone: May increase serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk C: Monitor

Nitroprusside: Blood Pressure Lowering Agents may increase hypotensive effects of Nitroprusside. Risk C: Monitor

Nonsteroidal Anti-Inflammatory Agents (Topical): May decrease therapeutic effects of Loop Diuretics. Risk C: Monitor

Nonsteroidal Anti-Inflammatory Agents: May decrease diuretic effects of Loop Diuretics. Loop Diuretics may increase nephrotoxic effects 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. Risk D: Consider Therapy Modification

Obinutuzumab: May increase hypotensive effects 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. Risk D: Consider Therapy Modification

Opioid Agonists: May increase adverse/toxic effects of Diuretics. Opioid Agonists may decrease therapeutic effects of Diuretics. Risk C: Monitor

Palopegteriparatide: Loop Diuretics may decrease therapeutic effects of Palopegteriparatide. Loop Diuretics may increase therapeutic effects of Palopegteriparatide. Risk C: Monitor

Pentoxifylline: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Perazine: May increase hypotensive effects of Antihypertensive Agents. Risk C: Monitor

Pholcodine: Blood Pressure Lowering Agents may increase hypotensive effects of Pholcodine. Risk C: Monitor

Phosphodiesterase 5 Inhibitors: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Piperacillin: May increase hypokalemic effects of Diuretics. Risk C: Monitor

Polyethylene Glycol-Electrolyte Solution: Diuretics may increase nephrotoxic effects of Polyethylene Glycol-Electrolyte Solution. Risk C: Monitor

Porfimer: Photosensitizing Agents may increase photosensitizing effects of Porfimer. Risk X: Avoid

Prazosin: Antihypertensive Agents may increase hypotensive effects of Prazosin. Risk C: Monitor

Pretomanid: May increase serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk C: Monitor

Probenecid: May decrease diuretic effects of Loop Diuretics. Probenecid may increase serum concentration of Loop Diuretics. Risk C: Monitor

Promazine: Loop Diuretics may increase QTc-prolonging effects of Promazine. Risk X: Avoid

Prostacyclin Analogues: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Quinagolide: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Reboxetine: May increase hypokalemic effects of Loop Diuretics. Risk C: Monitor

Salicylates: May decrease therapeutic effects of Loop Diuretics. Loop Diuretics may increase serum concentration of Salicylates. Risk C: Monitor

Silodosin: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Sodium Phosphates: Diuretics may increase nephrotoxic effects of Sodium Phosphates. Specifically, the risk of acute phosphate nephropathy may be enhanced. Risk C: Monitor

Taurursodiol: May increase serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk X: Avoid

Terazosin: Antihypertensive Agents may increase hypotensive effects of Terazosin. Risk C: Monitor

Teriflunomide: May increase serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk C: Monitor

Tobramycin (Oral Inhalation): Loop Diuretics may increase ototoxic effects of Tobramycin (Oral Inhalation). Loop Diuretics may increase nephrotoxic effects of Tobramycin (Oral Inhalation). Risk C: Monitor

Topiramate: Loop Diuretics may increase hypokalemic effects of Topiramate. Risk C: Monitor

Urapidil: Antihypertensive Agents may increase hypotensive effects of Urapidil. Risk C: Monitor

Vaborbactam: May increase serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk C: Monitor

Vadadustat: May increase serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk C: Monitor

Vancomycin: Loop Diuretics may increase nephrotoxic effects of Vancomycin. Risk C: Monitor

Verteporfin: Photosensitizing Agents may increase photosensitizing effects of Verteporfin. Risk C: Monitor

Warfarin: Torsemide may increase serum concentration of Warfarin. Risk C: Monitor

Xipamide: May increase adverse/toxic effects of Loop Diuretics. Specifically, the risk of hypovolemia, electrolyte disturbances, and prerenal azotemia may be increased. Risk C: Monitor

Zoledronic Acid: Loop Diuretics may increase hypocalcemic effects of Zoledronic Acid. Risk C: Monitor

Pregnancy Considerations

Adverse events have been observed in animal reproduction studies.

Breastfeeding Considerations

It is not known if torsemide is present in breast milk. Diuretics can suppress lactation.

Dietary Considerations

May cause potassium loss; potassium supplement or dietary changes may be required.

Monitoring Parameters

Kidney function; serum electrolytes; blood pressure; serum glucose; fluid intake and output.

Mechanism of Action

Inhibits reabsorption of sodium and chloride in the ascending loop of Henle and distal renal tubule, interfering with the chloride-binding cotransport system, thus causing increased excretion of water, sodium, chloride, magnesium, and calcium; does not alter GFR, renal plasma flow, or acid-base balance

Pharmacokinetics (Adult Data Unless Noted)

Onset of action: Diuresis: Within 1 hour.

Peak effect: Diuresis: 1 to 2 hours; Antihypertensive: 4 to 6 weeks (up to 12 weeks).

Duration: Diuresis: ~6 to 8 hours.

Distribution: Vd: 12 to 15 L; Cirrhosis: ~24 to 30 L.

Protein binding: >99%.

Metabolism: Hepatic (~80%) via CYP2C9 and to a minor extent, CYP2C8 and CYP2C18.

Bioavailability: ~80%.

Half-life elimination: ~3.5 hours.

Time to peak, plasma: Within 1 to 2.5 hours; delayed ~30 to 45 minutes when administered with food.

Excretion: Urine (21%).

Pharmacokinetics: Additional Considerations (Adult Data Unless Noted)

Altered kidney function: Renal clearance is markedly decreased in kidney failure; a smaller fraction of the administered dose is delivered to the intraluminal site of action, and the natriuretic action is reduced.

Hepatic function impairment: Volume of distribution, plasma half-life, and renal clearance are increased in patients with cirrhosis.

Heart failure: Hepatic and renal clearance are decreased. Total clearance is ~50% of that seen in healthy volunteers, and the plasma half-life and AUC are correspondingly increased.

Brand Names: International
International Brand Names by Country
For country code abbreviations (show table)

  • (AE) United Arab Emirates: Toras denk;
  • (AT) Austria: Torasemid hexal pharma;
  • (BD) Bangladesh: Dilast | Dytor | Luretic | Tomide | Torsid;
  • (BE) Belgium: Torasemide bexal | Torasemide sandoz | Torrem;
  • (BF) Burkina Faso: Sutrilneo | Toras denk;
  • (BG) Bulgaria: Torazidex | Torsit sr | Trifas | Trifas cor | Trigrim;
  • (CH) Switzerland: Toramid | Torasem | Torasemid actavis | Torasemid Helvepharm | Torasemid mepha | Torasemid Mylan | Torasemid sandoz | Torasemid Sandoz Eco | Torasemid Spirig | Torasemid spirig hc | Torasemid teva | Torasemid zentiva | Torasis | Torem;
  • (CI) Côte d'Ivoire: Sutrilneo;
  • (CN) China: Ta sai | Te su min | Tuo sai | Unat | Yi mai ge;
  • (CO) Colombia: Sutrilneo | Unat;
  • (DE) Germany: Toracard | Toradiur | Toragamma | Torasemid | Torasemid Aaa-Pharma | Torasemid abz | Torasemid Accedo | Torasemid al | Torasemid beta | Torasemid Biomo | Torasemid Corax | Torasemid Denk | Torasemid dura | Torasemid Heumann | Torasemid ratiopharm | Torasemid stada | Torasemid Volkspharma | Torasemid von ct | Torasemid-1a pharma | Torasid-gry | Torem | Torem Cor | Torem rr | Unat;
  • (DO) Dominican Republic: Britomar | Torsinex;
  • (EE) Estonia: Torasemide hexal | Torasemide teva | Trifas | Trifas cor;
  • (EG) Egypt: Cardiotimide | Examide | Onced | Retorinad | Torsamolex | Torseretic;
  • (ES) Spain: Dilutol | Dilutol hta | Isodiur | Isodiur hta | Sutril | Sutril hta | Sutril neo | Torasemida Alter | Torasemida aurobindo | Torasemida bayvit | Torasemida cinfa | Torasemida edigen | Torasemida Normon | Torasemida Pharmagenus | Torasemida ratiopharm | Torasemida sandoz | Torasemida tarbis | Torasemida teva | Torasemida UR | Torasemida Winthrop;
  • (ET) Ethiopia: Toras denk;
  • (GB) United Kingdom: Torasemide | Torasemide kent | Torem;
  • (GR) Greece: Tormis;
  • (HK) Hong Kong: Unat;
  • (HR) Croatia: Diuver | Tomid;
  • (ID) Indonesia: Toral | Unat;
  • (IE) Ireland: Torem;
  • (IN) India: Acotide | Concitor | Demator | Diurator | Dyamide | Dyloop | Dytor | Edeto | Flofre | Henletor | Ibmide | Jbtor | Lhd | Meltor | Nephtor | Nexmide | Retorlix | Semitor | Tide | Tomaris | Tor | Toracor | Toradic | Torain | Torcard | Torcel | Tordac | Torget | Toride | Toriflow | Tormax | Tormid | Tornem | Torpres | Torpride | Torsed | Torsemi | Torsia | Torsid | Torsikind | Torsilong | Torsinex | Torstar | Tortas | Tortec | Torvel | Torvigress | Tosec | Vitator | Zator;
  • (IT) Italy: Diuremid | Diuresix | Toradiur | Torasemide hex | Torasemide Mgi;
  • (JO) Jordan: Sutrilneo;
  • (JP) Japan: Luprac | Torasemide ko;
  • (KE) Kenya: Diuride | Diutor | Toras denk | Torsinex;
  • (KR) Korea, Republic of: Setoram | Tora | Torad | Torcin | Torem | Torsem | Torsemide | Torsin | Tosemid;
  • (LB) Lebanon: Sutrilneo;
  • (LT) Lithuania: Torasemid 1a pharma | Torasemide hexal | Torasemide pliva | Torasemide teva | Torem | Toridium | Trifas;
  • (LU) Luxembourg: Torasemid hexal | Torrem | Unat;
  • (LV) Latvia: Torasemid teva | Torasemide hexal | Torasemide teva | Torem | Trifas | Trifas cor;
  • (MA) Morocco: Tensemide;
  • (PE) Peru: Sutrilneo;
  • (PL) Poland: Diured | Diuver | Toramide | Torsemed | Trifas | Trifas cor | Unat;
  • (PR) Puerto Rico: Demadex | Soaanz | Torsemide;
  • (PT) Portugal: Tation;
  • (QA) Qatar: Torem;
  • (RU) Russian Federation: Britomar | Diuver | Lotonel | Torasemide canon | Torasemide medisorb | Torasemide sz | Torasemide teva | Trigrim;
  • (SE) Sweden: Torasemid actavis | Torasemid bluefish | Torasemid Ebb | Torasemid orifarm | Torasemid sandoz | Torem;
  • (SR) Suriname: Toras denk;
  • (TH) Thailand: Unat;
  • (TR) Turkey: Sutril neo;
  • (TW) Taiwan: Torsix;
  • (UA) Ukraine: Britomar | Dioren | Diutor | Diuver | Toraren | Torasemide darnitsa | Torasemide teva | Toricard | Torsid | Trifas;
  • (UG) Uganda: Cardiotimide | Tor loop | Toras denk | Torsamolex | Torsinex | Tortas;
  • (UY) Uruguay: Torem;
  • (ZA) South Africa: Risat | Torasemide biotech | Torsinat | Unat;
  • (ZM) Zambia: Tide | Toras denk;
  • (ZW) Zimbabwe: Torsid | Torsid 10 | Torsid 5
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