TORE-se-mide

• Edema due to:
  • HF,
  • Hepatic or renal disease.
• Hypertension.

• Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule.
• Increases renal excretion of water, sodium, chloride, magnesium, hydrogen, and calcium.
• Effectiveness persists in impaired renal function.

• Diuresis and subsequent mobilization of excess fluid (edema, pleural effusions).
• Decreased BP.

Absorption: 80% absorbed after oral administration.

Distribution: Widely distributed.

Protein Binding: 99%.

Metabolism/Excretion: Primarily metabolized by CYP2C9, with minor metabolism via CYP2C8 and CYP2C18. 80% metabolized by liver, 20% excreted in urine.

Half-life: 3.5 hr.

Contraindicated in:

• Hypersensitivity
• Cross-sensitivity with thiazides and sulfonamides may occur
• Hepatic coma
• Anuria.

Use Cautiously in:

• Severe liver disease (may precipitate hepatic coma; concurrent use with potassium-sparing diuretics may be necessary)
• Electrolyte depletion
• Severe renal impairment and hypoproteinemia (↑ risk of ototoxicity)
• Diabetes mellitus
• Increasing azotemia
• OB: Safety not established in pregnancy
• Lactation: Safety not established in breastfeeding
• Pedi: Safety and effectiveness not established in children
• Geri: Older adults may have ↑ risk of side effects, especially hypotension and electrolyte imbalance, at usual doses.

CV: hypotension.

Derm: STEVENS-JOHNSON SYNDROME (SJS), TOXIC EPIDERMAL NECROLYSIS (TEN), photosensitivity, rash.

EENT: hearing loss, tinnitus.

Endo: hyperglycemia.

F and E: dehydration, hypocalcemia, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis.

GI: constipation, diarrhea, dry mouth, dyspepsia, nausea, vomiting.

GU: acute renal failure, renal impairment, excessive urination.

Metab: hyperuricemia.

MS: arthralgia, muscle cramps, myalgia.

Neuro: dizziness, headache, nervousness.

Drug-Drug:

• ↑hypotension with antihypertensives, nitrates, or acute ingestion of alcohol.
• ↑risk of hypokalemia with other diuretics, amphotericin B, stimulant laxatives, and corticosteroids.
• Hypokalemia may ↑ risk of digoxin toxicity and ↑ risk of arrhythmia in patients taking drugs that prolong the QT interval.
• CYP2C9 inhibitors, including amiodarone, fluconazole, miconazole, and oxandrolone may ↑ levels and risk of toxicity.
• CYP2C9 inducers, including rifampin, may ↓ levels and effectiveness.
• May ↑ levels and risk of toxicity of CYP2C9 substrates, including celecoxib, phenytoin, or warfarin.
• ↑risk of nephrotoxicity with other nephrotoxic drugs, including aminoglycosides, cisplatin, NSAIDs, ACE inhibitors, angiotensin II receptor blockers and radiocontrast agents.
• May ↑ risk of lithium toxicity.
• ↑risk of ototoxicity with aminoglycosides.
• NSAIDs may ↓ effects.
• ↑risk of salicylate toxicity (with use of high-dose salicylate therapy).
• Cholestyramine may ↓ absorption.

Heart Failure

• PO (Adults): Generic or Soaanz — 20 mg once daily; dose may be doubled until desired effect is obtained (max = 200 mg/day).

Chronic Renal Failure

• PO (Adults): Generic or Soaanz — 20 mg once daily; dose may be doubled until desired effect is obtained (max = 200 mg/day).

Hepatic Cirrhosis

• PO (Adults): Generic only — 5–10 mg once daily (with aldosterone antagonist or potassium-sparing diuretic); dose may be doubled until desired effect is obtained (max = 40 mg/day).

Hypertension

• PO (Adults): Generic only — 2.5–5 mg once daily, may be ↑ to 10 mg once daily after 4–6 wk (if still not effective, add another agent).

• Administer medication in the morning to prevent disruption of sleep cycle.
• PO: May be taken with food or milk to minimize gastric irritation.

Demadex, Soaanz

Therapeutic Classification: antihypertensives

Pharmacologic Classification: loop diuretics

(Generic available)

• Tablets: 5 mg; 10 mg; 20 mg; 60 mg; 100 mg;
  • Cost: Generic— 5 mg; $63.42/100 10 mg; $70.27/100 20 mg; $82.08/100 100 mg; $304.00/100.

(diuretic effect)

• Assess fluid status during therapy. Monitor daily weight, intake and output ratios, amount and location of edema, lung sounds, skin turgor, and mucous membranes. Notify health care professional if thirst, dry mouth, lethargy, weakness, hypotension, or oliguria occurs.
• Monitor BP and pulse before and during administration. Monitor frequency of prescription refills to determine adherence in patients treated for hypertension.
• Assess patients receiving digoxin for anorexia, nausea, vomiting, muscle cramps, paresthesia, and confusion. Patients taking digoxin are at increased risk of digoxin toxicity due to potassium-depleting effect of the diuretic. Potassium supplements or potassium-sparing diuretics may be used concurrently to prevent hypokalemia.
• Assess patient for tinnitus and hearing loss. Audiometry is recommended for patients receiving prolonged high-dose IV therapy. Hearing loss is most common following rapid or high-dose IV administration in patients with decreased renal function or those taking other ototoxic drugs.
• Assess for allergy to sulfonamides.
• Assess patient for skin rash frequently during therapy. Discontinue torsemide at first sign of rash; may be life-threatening. SJS or TEN may develop. Treat symptomatically; may recur once treatment is stopped.
• Geri: Diuretic use is associated with increased risk for falls in older adults. Assess falls risk and implement fall prevention strategies.

• Monitor electrolytes, renal and hepatic function, serum glucose, and uric acid levels before and periodically during therapy. May cause ↓ serum sodium, potassium, calcium, and magnesium concentrations. May also cause ↑ BUN, serum glucose, serum creatinine, and uric acid levels.

• Instruct patient to take torsemide as directed. Take missed doses as soon as possible; do not double doses.
  • Caution patient to change positions slowly to minimize orthostatic hypotension. Caution patient that the use of alcohol, exercise during hot weather, or standing for long periods during therapy may enhance orthostatic hypotension.
  • Instruct patient to consult health care professional regarding a diet high in potassium (see Appendix M).
  • Advise patient to contact health care professional if they gain more than 2–3 lb/day.
  • Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking any OTC medications concurrently with this therapy.
  • Instruct patient to notify health care professional of medication regimen prior to treatment or surgery.
  • Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions.
  • Advise patient to contact health care professional immediately if rash muscle weakness, cramps, nausea, dizziness, numbness, or tingling of extremities occurs.
  • Advise diabetic patients to monitor blood glucose closely; may cause increased blood glucose levels.
  • Advise females of reproductive potential to notify health care professional if pregnancy is planned or suspected or if breastfeeding.
  • Emphasize the importance of routine follow-up examinations.
• Hypertension: Advise patients on antihypertensive regimen to continue taking medication even if feeling better. Torsemide controls but does not cure hypertension.
  • Reinforce the need to continue additional therapies for hypertension (weight loss, exercise, restricted sodium intake, stress reduction, regular exercise, moderation of alcohol consumption, cessation of smoking).

• Decrease in edema.
  • Decrease in abdominal girth and weight.
  • Increase in urinary output.
• Decrease in BP.

NDC Code^*

• 0037- Meda Pharmaceuticals
  • 0037-3500- Demadex
    • 0037-3500-01- 100 TABLET in 1 BOTTLE (0037-3500-01)

• 0054- West-Ward Pharmaceuticals Corp.
  • 0054-0077- Torsemide
    • 0054-0077-25- 100 TABLET in 1 BOTTLE, PLASTIC (0054-0077-25)

• 0054- West-Ward Pharmaceuticals Corp.
  • 0054-0077- Torsemide
    • 0054-0077-29- 500 TABLET in 1 BOTTLE, PLASTIC (0054-0077-29)

• 0517- American Regent, Inc.
  • 0517-0770- Torsemide
    • 0517-0770-10- 10 VIAL, SINGLE-DOSE in 1 CARTON (0517-0770-10) > 2 mL in 1 VIAL, SINGLE-DOSE (0517-0770-01)

• 0517- American Regent, Inc.
  • 0517-0771- Torsemide
    • 0517-0771-10- 10 VIAL, SINGLE-DOSE in 1 CARTON (0517-0771-10) > 5 mL in 1 VIAL, SINGLE-DOSE (0517-0771-01)

• 0615- NCS HealthCare of KY, Inc dba Vangard Labs
  • 0615-7997- Torsemide
    • 0615-7997-39- 30 TABLET in 1 BLISTER PACK (0615-7997-39)

• 31722- Camber Pharmaceuticals, Inc.
  • 31722-529- Torsemide
    • 31722-529-01- 100 TABLET in 1 BOTTLE (31722-529-01)

• 31722- Camber Pharmaceuticals, Inc.
  • 31722-529- Torsemide
    • 31722-529-05- 500 TABLET in 1 BOTTLE (31722-529-05)

• 31722- Camber Pharmaceuticals, Inc.
  • 31722-530- Torsemide
    • 31722-530-01- 100 TABLET in 1 BOTTLE (31722-530-01)

• 31722- Camber Pharmaceuticals, Inc.
  • 31722-530- Torsemide
    • 31722-530-05- 500 TABLET in 1 BOTTLE (31722-530-05)

• 31722- Camber Pharmaceuticals, Inc.
  • 31722-531- Torsemide
    • 31722-531-01- 100 TABLET in 1 BOTTLE (31722-531-01)

• 31722- Camber Pharmaceuticals, Inc.
  • 31722-531- Torsemide
    • 31722-531-05- 500 TABLET in 1 BOTTLE (31722-531-05)

• 31722- Camber Pharmaceuticals, Inc.
  • 31722-532- Torsemide
    • 31722-532-01- 100 TABLET in 1 BOTTLE (31722-532-01)

• 31722- Camber Pharmaceuticals, Inc.
  • 31722-532- Torsemide
    • 31722-532-05- 500 TABLET in 1 BOTTLE (31722-532-05)

• 42291- AvKARE, Inc.
  • 42291-816- Torsemide
    • 42291-816-90- 90 TABLET in 1 BOTTLE (42291-816-90)

• 42291- AvKARE, Inc.
  • 42291-817- Torsemide
    • 42291-817-90- 90 TABLET in 1 BOTTLE (42291-817-90)

• 42291- AvKARE, Inc.
  • 42291-818- Torsemide
    • 42291-818-90- 90 TABLET in 1 BOTTLE (42291-818-90)

• 42291- AvKARE, Inc.
  • 42291-819- Torsemide
    • 42291-819-90- 90 TABLET in 1 BOTTLE (42291-819-90)

• 43353- Aphena Pharma Solutions - Tennessee, LLC
  • 43353-315- Torsemide
    • 43353-315-16- 6000 TABLET in 1 BOTTLE, PLASTIC (43353-315-16)

• 50111- Teva Pharmaceuticals USA, Inc.
  • 50111-915- Torsemide
    • 50111-915-01- 100 TABLET in 1 BOTTLE (50111-915-01)

• 50111- Teva Pharmaceuticals USA, Inc.
  • 50111-916- Torsemide
    • 50111-916-01- 100 TABLET in 1 BOTTLE (50111-916-01)

• 50111- Teva Pharmaceuticals USA, Inc.
  • 50111-917- Torsemide
    • 50111-917-01- 100 TABLET in 1 BOTTLE (50111-917-01)

• 50111- Teva Pharmaceuticals USA, Inc.
  • 50111-917- Torsemide
    • 50111-917-03- 1000 TABLET in 1 BOTTLE (50111-917-03)

• 50111- Teva Pharmaceuticals USA, Inc.
  • 50111-918- Torsemide
    • 50111-918-01- 100 TABLET in 1 BOTTLE (50111-918-01)

• 50268- AvPAK
  • 50268-754- Torsemide
    • 50268-754-15- 50 BLISTER PACK in 1 BOX, UNIT-DOSE (50268-754-15) > 1 TABLET in 1 BLISTER PACK (50268-754-11)

• 50268- AvPAK
  • 50268-755- Torsemide
    • 50268-755-15- 50 BLISTER PACK in 1 BOX, UNIT-DOSE (50268-755-15) > 1 TABLET in 1 BLISTER PACK (50268-755-11)

• 50268- AvPAK
  • 50268-756- Torsemide
    • 50268-756-15- 50 BLISTER PACK in 1 BOX, UNIT-DOSE (50268-756-15) > 1 TABLET in 1 BLISTER PACK (50268-756-11)

• 50268- AvPAK
  • 50268-757- Torsemide
    • 50268-757-15- 50 BLISTER PACK in 1 BOX, UNIT-DOSE (50268-757-15) > 1 TABLET in 1 BLISTER PACK (50268-757-11)

• 57237- Rising Health, LLC
  • 57237-138- Torsemide
    • 57237-138-01- 100 TABLET in 1 BOTTLE (57237-138-01)

• 57237- Rising Health, LLC
  • 57237-139- Torsemide
    • 57237-139-01- 100 TABLET in 1 BOTTLE (57237-139-01)

• 57237- Rising Health, LLC
  • 57237-140- Torsemide
    • 57237-140-01- 100 TABLET in 1 BOTTLE (57237-140-01)

• 57237- Rising Health, LLC
  • 57237-141- Torsemide
    • 57237-141-01- 100 TABLET in 1 BOTTLE (57237-141-01)

• 63629- Bryant Ranch Prepack
  • 63629-1346- Torsemide
    • 63629-1346-1- 100 TABLET in 1 BOTTLE (63629-1346-1)

• 63629- Bryant Ranch Prepack
  • 63629-1346- Torsemide
    • 63629-1346-2- 30 TABLET in 1 BOTTLE (63629-1346-2)

• 65862- Aurobindo Pharma Limited
  • 65862-125- Torsemide
    • 65862-125-01- 100 TABLET in 1 BOTTLE (65862-125-01)

• 65862- Aurobindo Pharma Limited
  • 65862-125- Torsemide
    • 65862-125-99- 1000 TABLET in 1 BOTTLE (65862-125-99)

• 65862- Aurobindo Pharma Limited
  • 65862-126- Torsemide
    • 65862-126-01- 100 TABLET in 1 BOTTLE (65862-126-01)

• 65862- Aurobindo Pharma Limited
  • 65862-126- Torsemide
    • 65862-126-99- 1000 TABLET in 1 BOTTLE (65862-126-99)

• 65862- Aurobindo Pharma Limited
  • 65862-127- Torsemide
    • 65862-127-01- 100 TABLET in 1 BOTTLE (65862-127-01)

• 65862- Aurobindo Pharma Limited
  • 65862-127- Torsemide
    • 65862-127-99- 1000 TABLET in 1 BOTTLE (65862-127-99)

• 65862- Aurobindo Pharma Limited
  • 65862-128- Torsemide
    • 65862-128-01- 100 TABLET in 1 BOTTLE (65862-128-01)

• 65862- Aurobindo Pharma Limited
  • 65862-128- Torsemide
    • 65862-128-99- 1000 TABLET in 1 BOTTLE (65862-128-99)

• 68084- American Health Packaging
  • 68084-539- Torsemide
    • 68084-539-01- 100 BLISTER PACK in 1 CARTON (68084-539-01) > 1 TABLET in 1 BLISTER PACK (68084-539-11)

• 70518- REMEDYREPACK INC.
  • 70518-2195- Torsemide
    • 70518-2195-0- 90 TABLET in 1 BOTTLE, PLASTIC (70518-2195-0)

• 71335- Bryant Ranch Prepack
  • 71335-0297- Torsemide
    • 71335-0297-1- 100 TABLET in 1 BOTTLE (71335-0297-1)

• 71335- Bryant Ranch Prepack
  • 71335-0297- Torsemide
    • 71335-0297-2- 30 TABLET in 1 BOTTLE (71335-0297-2)

• 72189- Direct_Rx
  • 72189-030- TORSEMIDE
    • 72189-030-30- 30 TABLET in 1 BOTTLE (72189-030-30)