Edema 
Torsemide is used for the management of edema associated with heart failure1,12,13,524 or hepatic1,12,13,14 or renal1,12,13 disease. Most experts state that all patients with symptomatic heart failure who have evidence for, or a history of, fluid retention generally should receive diuretic therapy in conjunction with moderate sodium restriction, an agent to inhibit the renin-angiotensin-aldosterone (RAA) system (e.g., angiotensin-converting enzyme [ACE] inhibitor, angiotensin II receptor antagonist, angiotensin receptor-neprilysin inhibitor [ARNI]), a β-adrenergic blocking agent (β-blocker), and in selected patients, an aldosterone antagonist.524,700,713 For additional information on the use of loop diuretics in the management of edema associated with heart failure,14 see Heart Failure under Uses: Edema, in Bumetanide, Ethacrynic Acid, and Furosemide 40:28.08.
Hypertension
Torsemide is used alone or in combination with other classes of antihypertensive agents for the management of hypertension.1,3,12,13,14 Because of established clinical benefits (e.g., reductions in overall mortality and in adverse cardiovascular, cerebrovascular, and renal outcomes), current evidence-based practice guidelines for the management of hypertension in adults generally recommend the use of drugs from 4 classes of antihypertensive agents (ACE inhibitors, angiotensin II receptor antagonists, calcium-channel blockers, and thiazide diuretics).501,502,503,504,1200 (See Uses: Hypertension in Adults, in the Thiazides General Statement 40:28.20.) However, some experts state that loop diuretics (e.g., bumetanide, furosemide, torsemide) are preferred over thiazides in patients with moderate to severe chronic kidney disease (CKD)502,504,1200 or symptomatic heart failure.524,1200 Loop diuretics may be particularly useful in patients with heart failure and reduced left ventricular ejection fraction (LVEF) who have evidence of fluid retention; however, some experts state that thiazide diuretics may be considered in hypertensive patients with heart failure and mild fluid retention because of their more persistent antihypertensive effect.524
For further information on the role of diuretics in antihypertensive drug therapy and information on overall principles and expert recommendations for treatment of hypertension, see Uses: Hypertension in Adults, and also see Uses: Hypertension in Pediatric Patients, in the Thiazides General Statement 40:28.20.
Administration
Torsemide usually is administered orally.1,12,13 Food decreases the rate but not the extent of GI absorption, and the manufacturers state that the drug may be administered without regard to meals.1,12,13
Torsemide also may be given by IV injection when a rapid onset of diuresis is desired or when oral therapy is not practical.1,12 IV injections of torsemide should be administered slowly over 2 minutes (“bolus”); alternatively, the drug may be administered as a continuous IV infusion.1,12,14
If torsemide injection is administered through an IV line, it is recommended that the IV line be flushed with 0.9% sodium chloride injection before and after the drug is administered.14 Because the pH of torsemide injection exceeds 8.3, flushing is necessary to avoid potential incompatibilities that may result from differences in pH.14
For administration of torsemide as a continuous IV infusion, 200 mg of the drug may be diluted in 250 mL of 5% dextrose or 0.9% sodium chloride injection or in 500 mL of 0.45% sodium chloride injection; alternatively, 50 mg of torsemide may be diluted in 500 mL of 5% dextrose, 0.9% sodium chloride injection, or 0.45% sodium chloride injection.14 Following dilution in these solutions in plastic containers, the drug is stable for up to 24 hours at room temperature.14
Dosage
The manufacturers state that since oral and IV doses of torsemide are therapeutically equivalent, torsemide dosage is identical for oral or IV administration.1,12,14
For the management of fluid retention (e.g., edema) associated with heart failure, experts state that diuretics should be administered at a dosage sufficient to achieve optimal volume status and relieve congestion without inducing an excessively rapid reduction in intravascular volume, which could result in hypotension, renal dysfunction, or both.524
Safety and efficacy of torsemide in children have not been established.1,12,13,14
Edema
For the management of edema associated with heart failure, the usual initial adult oral or IV dosage of torsemide is 10-20 mg daily, given as a single dose.1,12,13,14 If the diuretic response is inadequate, dosage can be titrated upward by approximately doubling the daily dose until the desired response is attained.1,12,13,14 The manufacturers state that single doses exceeding 200 mg have not been adequately studied.1,12,13,14 Some experts recommend initiating torsemide at a low dosage (10-20 mg once daily) and increasing the dosage (maximum of 200 mg daily) until urine output increases and weight decreases, generally by 0.5-1 kg daily.524
Hypertension
For the management of hypertension, the usual initial adult dosage of torsemide recommended by the manufacturers is 5 mg once daily.1,13,14 If a satisfactory lowering of blood pressure does not occur within 4-6 weeks, dosage of torsemide may be increased to 10 mg once daily.1,13,14 Some experts state that the usual dosage of torsemide is 5-10 mg once daily.1200 If a satisfactory lowering of blood pressure does not occur when 10 mg is administered daily, other antihypertensive agents should be added to the regimen.1,13,14
Monitoring and Blood Pressure Treatment Goals
The patient's renal function and electrolytes should be assessed 2-4 weeks after initiation of diuretic therapy.1200 Blood pressure should be monitored regularly (i.e., monthly) during therapy and dosage of the antihypertensive drug adjusted until blood pressure is controlled.1200 If an adequate blood pressure response is not achieved, the dosage may be increased or another antihypertensive agent with demonstrated benefit and preferably with a complementary mechanism of action (e.g., angiotensin-converting enzyme [ACE] inhibitor, angiotensin II receptor antagonist, calcium-channel blocker) may be added; if target blood pressure is still not achieved, a third drug may be added.1200,1216 (See Uses: Hypertension in Adults, in the Thiazides General Statement 40:28.20.) In patients who develop unacceptable adverse effects with torsemide, the drug should be discontinued and another antihypertensive agent from a different pharmacologic class should be initiated.1216
The goal of hypertension management and prevention is to achieve and maintain optimal control of blood pressure.1200 However, the optimum blood pressure threshold for initiating antihypertensive drug therapy and specific treatment goals remain controversial.505,506,507,508,515,1201,1207,1209,1222 A 2017 multidisciplinary hypertension guideline from the American College of Cardiology (ACC), American Heart Association (AHA), and a number of other professional organizations generally recommends a blood pressure goal of less than 130/80 mm Hg in all adults, regardless of comorbidities or level of atherosclerotic cardiovascular disease (ASCVD) risk.1200,1207 Many patients will require at least 2 drugs from different pharmacologic classes to achieve this blood pressure goal; the potential benefits of hypertension management and drug cost, adverse effects, and risks associated with the use of multiple antihypertensive drugs also should be considered when deciding a patient's blood pressure treatment goal.1200,1220
For additional information on target levels of blood pressure and on monitoring therapy, see Blood Pressure Monitoring and Treatment Goals under Dosage: Hypertension, in Dosage and Administration in the Thiazides General Statement 40:28.20.
Dosage in Renal and Hepatic Impairment
For the management of edema in patients with chronic renal failure, the usual initial adult oral or IV dosage of torsemide is 20 mg daily, given as a single dose.1,12,13,14 If the diuretic response is inadequate, dosage may be titrated upward by doubling the dose until desired response is attained.1,12,13,14 However, the manufacturers state that single doses exceeding 200 mg or chronic use in patients with renal impairment have not been adequately studied.1,13,14
For the management of edema in patients with hepatic cirrhosis, torsemide is administered concomitantly with an aldosterone antagonist or a potassium-sparing diuretic; the usual initial adult oral or IV dosage of torsemide is 5-10 mg daily, given as a single dose.1,12,13,14 If the diuretic response to this initial dosage is inadequate, dosage may be titrated upward by doubling the dose until the desired response is attained.1,12,13,14 Single doses exceeding 40 mg have not been adequately studied in patients with hepatic cirrhosis.1,12,13,14
1. Boehringer Mannheim. Demadex® (torsemide) tablets and injection prescribing information. Rockville, MD: 1993 Oct.
3. Kaplan NM. Choice of initial therapy for hypertension. JAMA . 1996; 275:1577-80. [PubMed 8622249]
5. Izzo JL, Levy D, Black HR. Importance of systolic blood pressure in older Americans. Hypertension . 2000; 35:1021-4. [PubMed 10818056]
6. Frohlich ED. Recognition of systolic hypertension for hypertension. Hypertension . 2000; 35:1019-20. [PubMed 10818055]
7. Bakris GL, Williams M, Dworkin L et al. Preserving renal function in adults with hypertension and diabetes: a consensus approach. Am J Kidney Dis . 2000; 36:646-61. [PubMed 10977801]
8. Associated Press (American Diabetes Association). Diabetics urged: drop blood pressure. Chicago, IL; 2000 Aug 29. Press Release from web site. [Web]
9. Appel LJ. The verdict from ALLHAT—thiazide diuretics are the preferred initial therapy for hypertension. JAMA . 2002; 288:3039-42. [PubMed 12479770]
10. The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA . 2002; 288:2981-97. [PubMed 12479763]
12. Roche Pharmaceuticals. Demadex® (torsemide) tablets and injection prescribing information. Nutley, NJ: 2003 Apr.
13. Meda Demadex® (torsemide) tablets prescribing information. Somerset, NJ: 2010 Feb.
14. American Regent. Torsemide injection prescribing information. Shirley, NY: 2009 Dec.
15. American Society of Health-System Pharmacists: Shortage and resumed manufacturing of torsemide Injection. [Web]/Drug Shortages/Current/bulletin.aspx?id=344. Accessed Oct. 4 2011
16. Vargo DL, Kramer WG, Black PK et al. Bioavailability, pharmacokinetics, and pharmacodynamics of torsemide and furosemide in patients with congestive heart failure. Clin Pharmacol Ther . 1995; 57:601-9 [PubMed 7781259]
17. American Regent announces increased production and availability of torsemide injection. New York; 2011;Feb 8. Press Release. . Clin Pharmacol Ther . 1994;56:48-54. [PubMed 8033494]
18. Kramer WG , Smith WB, Ferguson J et al. Pharmacodynamics of torsemide administered as an intravenous injection and as a continuous infusion to patients with congestive heart failure. J Clinical Pharmacol . 1996;36:265-270.
501. James PA, Oparil S, Carter BL et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA . 2014; 311:507-20. [PubMed 24352797]
502. Mancia G, Fagard R, Narkiewicz K et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens . 2013; 31:1281-357. [PubMed 23817082]
503. Go AS, Bauman MA, Coleman King SM et al. An effective approach to high blood pressure control: a science advisory from the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention. Hypertension . 2014; 63:878-85. [PubMed 24243703]
504. Weber MA, Schiffrin EL, White WB et al. Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and the International Society of Hypertension. J Clin Hypertens (Greenwich) . 2014; 16:14-26. [PubMed 24341872]
505. Wright JT, Fine LJ, Lackland DT et al. Evidence supporting a systolic blood pressure goal of less than 150 mm Hg in patients aged 60 years or older: the minority view. Ann Intern Med . 2014; 160:499-503. [PubMed 24424788]
506. Mitka M. Groups spar over new hypertension guidelines. JAMA . 2014; 311:663-4. [PubMed 24549531]
507. Peterson ED, Gaziano JM, Greenland P. Recommendations for treating hypertension: what are the right goals and purposes?. JAMA . 2014; 311:474-6. [PubMed 24352710]
508. Bauchner H, Fontanarosa PB, Golub RM. Updated guidelines for management of high blood pressure: recommendations, review, and responsibility. JAMA . 2014; 311:477-8. [PubMed 24352759]
515. Thomas G, Shishehbor M, Brill D et al. New hypertension guidelines: one size fits most?. Cleve Clin J Med . 2014; 81:178-88. [PubMed 24591473]
523. Fihn SD, Gardin JM, Abrams J et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation . 2012; 126:e354-471.
524. WRITING COMMITTEE MEMBERS, Yancy CW, Jessup M et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation . 2013; 128:e240-327.
526. Kernan WN, Ovbiagele B, Black HR et al. Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke . 2014; 45:2160-2236. [PubMed 24788967]
530. Myers MG, Tobe SW. A Canadian perspective on the Eighth Joint National Committee (JNC 8) hypertension guidelines. J Clin Hypertens (Greenwich) . 2014; 16:246-8. [PubMed 24641124]
536. Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group. KDIGO clinical practice guideline for the management of blood pressure in chronic kidney disease. Kidney Int Suppl . 2012: 2: 337-414.
700. Yancy CW, Jessup M, Bozkurt B et al. 2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation . 2016; :.
713. Gupta D, Georgiopoulou VV, Kalogeropoulos AP et al. Dietary sodium intake in heart failure. Circulation . 2012; 126:479-85. [PubMed 22825409]
1200. Whelton PK, Carey RM, Aronow WS et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension . 2018; 71:el13-e115. [PubMed 29133356]
1201. Bakris G, Sorrentino M. Redefining hypertension - assessing the new blood-pressure guidelines. N Engl J Med . 2018; 378:497-499. [PubMed 29341841]
1202. Carey RM, Whelton PK, 2017 ACC/AHA Hypertension Guideline Writing Committee. Prevention, detection, evaluation, and management of high blood pressure in adults: synopsis of the 2017 American College of Cardiology/American Heart Association hypertension guideline. Ann Intern Med . 2018; 168:351-358. [PubMed 29357392]
1207. Burnier M, Oparil S, Narkiewicz K et al. New 2017 American Heart Association and American College of Cardiology guideline for hypertension in the adults: major paradigm shifts, but will they help to fight against the hypertension disease burden?. Blood Press . 2018; 27:62-65. [PubMed 29447001]
1209. Qaseem A, Wilt TJ, Rich R et al. Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med . 2017; 166:430-437. [PubMed 28135725]
1210. SPRINT Research Group, Wright JT, Williamson JD et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med . 2015; 373:2103-16. [PubMed 26551272]
1216. Taler SJ. Initial treatment of hypertension. N Engl J Med . 2018; 378:636-644. [PubMed 29443671]
1220. Cifu AS, Davis AM. Prevention, detection, evaluation, and management of high blood pressure in adults. JAMA . 2017; 318:2132-2134. [PubMed 29159416]
1222. Bell KJL, Doust J, Glasziou P. Incremental benefits and harms of the 2017 American College of Cardiology/American Heart Association high blood pressure guideline. JAMA Intern Med . 2018; 178:755-7. [PubMed 29710197]
1223. LeFevre M. ACC/AHA hypertension guideline: what is new? what do we do?. Am Fam Physician . 2018; 97(6):372-3. [PubMed 29671534]
1224. Brett AS. New hypertension guideline is released. From NEJM Journal Watch website. Accessed 2018 Jun 18. [Web]
1229. Ioannidis JPA. Diagnosis and treatment of hypertension in the 2017 ACC/AHA guidelines and in the real world. JAMA . 2018; 319(2):115-6. [PubMed 29242891]