Torsemide 20mg Tablets
It is used to get rid of extra fluid. It is used to treat high blood pressure.
Drug Class
Diuretic
Pharmacologic Class
Loop Diuretic
Pregnancy Category
C
FDA Approved
Dec 1993
DEA Schedule
Not Controlled
Overview
What is this medicine?
Torsemide is a 'water pill' (diuretic) that helps your body get rid of extra salt and water. This helps to lower blood pressure and reduce swelling (edema) caused by conditions like heart failure, kidney disease, or liver disease.
How to Use This Medicine
Taking Your Medication Correctly
To get the most benefit from your medication, follow your doctor's instructions carefully. Read all the information provided with your prescription and follow the instructions closely. This medication may increase your urine production, so try to avoid taking it too close to bedtime to minimize sleep disturbances. Continue taking your medication as directed by your doctor or healthcare provider, even if you start feeling better.
If you are also taking cholestyramine, consult with your pharmacist to determine the best way to take these medications together.
Storing and Disposing of Your Medication
Store your medication at room temperature in a dry location, avoiding bathrooms and areas where children and pets can access it. Keep all medications in a safe place and out of reach of children and pets. Dispose of unused or expired medications properly. Do not flush them down the toilet or pour them down the drain unless instructed to do so. If you have questions about disposing of your medication, consult with your pharmacist. You may also want to check if there are any drug take-back programs in your area.
What to Do If You Miss a Dose
If you miss a dose, take it as soon as you remember. However, if it is close to the time for your next scheduled dose, skip the missed dose and resume your regular dosing schedule. Do not take two doses at the same time or take extra doses to make up for a missed dose.
To get the most benefit from your medication, follow your doctor's instructions carefully. Read all the information provided with your prescription and follow the instructions closely. This medication may increase your urine production, so try to avoid taking it too close to bedtime to minimize sleep disturbances. Continue taking your medication as directed by your doctor or healthcare provider, even if you start feeling better.
If you are also taking cholestyramine, consult with your pharmacist to determine the best way to take these medications together.
Storing and Disposing of Your Medication
Store your medication at room temperature in a dry location, avoiding bathrooms and areas where children and pets can access it. Keep all medications in a safe place and out of reach of children and pets. Dispose of unused or expired medications properly. Do not flush them down the toilet or pour them down the drain unless instructed to do so. If you have questions about disposing of your medication, consult with your pharmacist. You may also want to check if there are any drug take-back programs in your area.
What to Do If You Miss a Dose
If you miss a dose, take it as soon as you remember. However, if it is close to the time for your next scheduled dose, skip the missed dose and resume your regular dosing schedule. Do not take two doses at the same time or take extra doses to make up for a missed dose.
Lifestyle & Tips
- Take exactly as prescribed, usually once daily in the morning to avoid nighttime urination.
- Do not stop taking without consulting your doctor, even if you feel better.
- Monitor your weight daily and report any sudden changes (e.g., gain or loss of more than 2-3 pounds in a day).
- Follow your doctor's recommendations for diet, especially regarding salt intake.
- Be aware of signs of dehydration (e.g., excessive thirst, dry mouth, dizziness) and electrolyte imbalance (e.g., muscle cramps, weakness, irregular heartbeat).
- Avoid excessive alcohol consumption, as it can increase the risk of dizziness and dehydration.
- Stand up slowly from a sitting or lying position to prevent dizziness or lightheadedness.
Available Forms & Alternatives
Dosing & Administration
Adult Dosing
Standard Dose:
Hypertension: 5 mg once daily; Edema (CHF, renal, hepatic): 10-20 mg once daily
Dose Range:
5 - 200 mg
Condition-Specific Dosing:
hypertension:
Initial: 5 mg once daily; may increase to 10 mg after 4-6 weeks if needed.
edema_CHF:
Initial: 10-20 mg once daily; may increase up to 200 mg once daily.
edema_renal:
Initial: 20 mg once daily; may increase up to 200 mg once daily.
edema_hepatic:
Initial: 5-10 mg once daily with an aldosterone antagonist; may increase up to 40 mg once daily.
Pediatric Dosing
Neonatal:
Not established
Infant:
Not established
Child:
Not established
Adolescent:
Not established
Dose Adjustments
Renal Impairment:
Mild:
No dosage adjustment typically required.
Moderate:
No dosage adjustment typically required, but monitor closely.
Severe:
Initial dose 20 mg once daily, may increase up to 200 mg once daily if needed. Monitor closely for efficacy and adverse effects.
Dialysis:
Torsemide is not significantly removed by hemodialysis. Dosage adjustment may not be necessary, but monitor fluid status and electrolytes closely.
Hepatic Impairment:
Mild:
No specific adjustment, but monitor closely.
Moderate:
Initial dose 5-10 mg once daily with an aldosterone antagonist; use with caution and monitor for signs of hepatic coma.
Severe:
Use with extreme caution; contraindicated in hepatic coma or pre-coma states. Max dose 40 mg once daily with an aldosterone antagonist.
Pharmacology
Mechanism of Action
Torsemide is a loop diuretic that acts on the thick ascending limb of the loop of Henle. It inhibits the Na+/K+/2Cl- cotransporter (NKCC2), thereby decreasing the reabsorption of sodium, potassium, and chloride. This leads to increased excretion of water, sodium, chloride, and potassium, resulting in diuresis and natriuresis. It also has a mild aldosterone antagonist effect.
Pharmacokinetics
Absorption:
Bioavailability:
80-90%
Tmax:
1 hour
FoodEffect:
Food delays Tmax by approximately 30 minutes but does not affect bioavailability.
Distribution:
Vd:
12-18 L
ProteinBinding:
97-99%
CnssPenetration:
Limited
Elimination:
HalfLife:
3.5 hours (range 2.1-4.0 hours)
Clearance:
Approximately 40 mL/min
ExcretionRoute:
Renal (primarily as metabolites, small amount as unchanged drug)
Unchanged:
Approximately 20-25%
Pharmacodynamics
OnsetOfAction:
Within 1 hour (oral)
PeakEffect:
1-2 hours
DurationOfAction:
6-8 hours
Safety & Warnings
Side Effects
Urgent Side Effects: Seek Medical Attention Immediately
Although rare, some people may experience severe and potentially life-threatening side effects while taking this medication. If you notice any of the following symptoms, contact your doctor or seek medical help right away:
Signs of an allergic reaction, such as:
+ Rash
+ Hives
+ Itching
+ Red, swollen, blistered, or peeling skin with or without fever
+ Wheezing
+ Tightness in the chest or throat
+ Trouble breathing, swallowing, or talking
+ Unusual hoarseness
+ Swelling of the mouth, face, lips, tongue, or throat
Signs of fluid and electrolyte problems, including:
+ Mood changes
+ Confusion
+ Muscle pain or weakness
+ Fast or abnormal heartbeat
+ Severe dizziness or passing out
+ Increased thirst
+ Seizures
+ Feeling very tired or weak
+ Decreased appetite
+ Unable to pass urine or change in the amount of urine produced
+ Dry mouth
+ Dry eyes
+ Severe upset stomach or vomiting
Signs of high blood sugar, such as:
+ Confusion
+ Feeling sleepy
+ Unusual thirst or hunger
+ Passing urine more often
+ Flushing
+ Fast breathing
+ Breath that smells like fruit
Signs of kidney problems, including:
+ Unable to pass urine
+ Change in how much urine is passed
+ Blood in the urine
+ Sudden weight gain
Severe dizziness or passing out
Ringing in the ears
* Hearing loss (although rare, this may occur, especially in people with kidney problems or those taking high doses of this medication)
If you experience any hearing problems, such as hearing loss, contact your doctor immediately.
Other Possible Side Effects
Like all medications, this drug can cause side effects. However, many people do not experience any side effects or only have mild ones. If you have any side effects that bother you or do not go away, contact your doctor or seek medical help.
This is not an exhaustive list of all possible side effects. If you have questions or concerns about side effects, contact your doctor. You can also report side effects to the FDA at 1-800-332-1088 or online at https://www.fda.gov/medwatch.
Although rare, some people may experience severe and potentially life-threatening side effects while taking this medication. If you notice any of the following symptoms, contact your doctor or seek medical help right away:
Signs of an allergic reaction, such as:
+ Rash
+ Hives
+ Itching
+ Red, swollen, blistered, or peeling skin with or without fever
+ Wheezing
+ Tightness in the chest or throat
+ Trouble breathing, swallowing, or talking
+ Unusual hoarseness
+ Swelling of the mouth, face, lips, tongue, or throat
Signs of fluid and electrolyte problems, including:
+ Mood changes
+ Confusion
+ Muscle pain or weakness
+ Fast or abnormal heartbeat
+ Severe dizziness or passing out
+ Increased thirst
+ Seizures
+ Feeling very tired or weak
+ Decreased appetite
+ Unable to pass urine or change in the amount of urine produced
+ Dry mouth
+ Dry eyes
+ Severe upset stomach or vomiting
Signs of high blood sugar, such as:
+ Confusion
+ Feeling sleepy
+ Unusual thirst or hunger
+ Passing urine more often
+ Flushing
+ Fast breathing
+ Breath that smells like fruit
Signs of kidney problems, including:
+ Unable to pass urine
+ Change in how much urine is passed
+ Blood in the urine
+ Sudden weight gain
Severe dizziness or passing out
Ringing in the ears
* Hearing loss (although rare, this may occur, especially in people with kidney problems or those taking high doses of this medication)
If you experience any hearing problems, such as hearing loss, contact your doctor immediately.
Other Possible Side Effects
Like all medications, this drug can cause side effects. However, many people do not experience any side effects or only have mild ones. If you have any side effects that bother you or do not go away, contact your doctor or seek medical help.
This is not an exhaustive list of all possible side effects. If you have questions or concerns about side effects, contact your doctor. You can also report side effects to the FDA at 1-800-332-1088 or online at https://www.fda.gov/medwatch.
Seek Immediate Medical Attention If You Experience:
- Severe dizziness or fainting
- Signs of dehydration (extreme thirst, dry mouth, decreased urination)
- Muscle cramps, weakness, or irregular heartbeat (signs of electrolyte imbalance)
- Numbness or tingling in hands or feet
- Unusual tiredness or confusion
- Sudden decrease in urine output
- Yellowing of skin or eyes (jaundice)
- Severe stomach pain, nausea, or vomiting
- Hearing loss or ringing in the ears
Before Using This Medicine
Before Taking This Medication: Important Information to Share with Your Doctor
It is essential to inform your doctor about the following conditions to ensure safe treatment:
Any allergies you have, including allergies to this medication, its components, or other substances, such as foods or drugs. Be sure to describe the symptoms you experienced.
If you have difficulty urinating or are unable to pass urine.
If you have been diagnosed with liver disease.
If you are taking any medications that may increase the risk of hearing problems. There are several drugs that can cause this issue, so consult your doctor or pharmacist if you are unsure.
Additionally, to avoid potential interactions, provide your doctor and pharmacist with a comprehensive list of:
All prescription and over-the-counter (OTC) medications you are currently taking.
Any natural products or vitamins you are using.
* Your complete medical history, including any health problems you have.
It is crucial to verify that it is safe to take this medication with all your other medications and health conditions. Never start, stop, or change the dosage of any medication without first consulting your doctor.
It is essential to inform your doctor about the following conditions to ensure safe treatment:
Any allergies you have, including allergies to this medication, its components, or other substances, such as foods or drugs. Be sure to describe the symptoms you experienced.
If you have difficulty urinating or are unable to pass urine.
If you have been diagnosed with liver disease.
If you are taking any medications that may increase the risk of hearing problems. There are several drugs that can cause this issue, so consult your doctor or pharmacist if you are unsure.
Additionally, to avoid potential interactions, provide your doctor and pharmacist with a comprehensive list of:
All prescription and over-the-counter (OTC) medications you are currently taking.
Any natural products or vitamins you are using.
* Your complete medical history, including any health problems you have.
It is crucial to verify that it is safe to take this medication with all your other medications and health conditions. Never start, stop, or change the dosage of any medication without first consulting your doctor.
Precautions & Cautions
It is essential to inform all your healthcare providers, including doctors, nurses, pharmacists, and dentists, that you are taking this medication.
To ensure your safety, avoid driving and other activities that require alertness until you understand how this drug affects you. When getting up from a sitting or lying down position, rise slowly to minimize the risk of dizziness or fainting. Be cautious when navigating stairs.
If you have diabetes (high blood sugar), it is crucial to monitor your blood sugar levels closely. Additionally, check your blood pressure as directed by your healthcare provider. Your doctor may also request regular blood tests to monitor your condition; be sure to discuss any concerns or questions with your doctor.
If you follow a low-salt or salt-free diet, consult with your doctor to ensure safe use of this medication. Furthermore, if you have high blood pressure and are taking this drug, consult your doctor before using over-the-counter (OTC) products that may increase blood pressure, such as cough or cold medications, diet pills, stimulants, non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen, and certain natural products or aids.
This medication is a potent diuretic, which can lead to excessive loss of water and electrolytes (including potassium) in the blood. This may cause severe health issues. Your doctor will closely monitor you and adjust the dosage as needed to meet your body's requirements. You may require additional potassium; discuss this with your doctor.
If you experience excessive sweating, fluid loss, vomiting, or diarrhea, inform your doctor, as these conditions may lead to low blood pressure. Also, be aware of potential gout attacks and report any symptoms to your doctor.
If you are pregnant, plan to become pregnant, or are breastfeeding, it is essential to discuss the benefits and risks of this medication with your doctor to ensure the best possible outcome for you and your baby.
To ensure your safety, avoid driving and other activities that require alertness until you understand how this drug affects you. When getting up from a sitting or lying down position, rise slowly to minimize the risk of dizziness or fainting. Be cautious when navigating stairs.
If you have diabetes (high blood sugar), it is crucial to monitor your blood sugar levels closely. Additionally, check your blood pressure as directed by your healthcare provider. Your doctor may also request regular blood tests to monitor your condition; be sure to discuss any concerns or questions with your doctor.
If you follow a low-salt or salt-free diet, consult with your doctor to ensure safe use of this medication. Furthermore, if you have high blood pressure and are taking this drug, consult your doctor before using over-the-counter (OTC) products that may increase blood pressure, such as cough or cold medications, diet pills, stimulants, non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen, and certain natural products or aids.
This medication is a potent diuretic, which can lead to excessive loss of water and electrolytes (including potassium) in the blood. This may cause severe health issues. Your doctor will closely monitor you and adjust the dosage as needed to meet your body's requirements. You may require additional potassium; discuss this with your doctor.
If you experience excessive sweating, fluid loss, vomiting, or diarrhea, inform your doctor, as these conditions may lead to low blood pressure. Also, be aware of potential gout attacks and report any symptoms to your doctor.
If you are pregnant, plan to become pregnant, or are breastfeeding, it is essential to discuss the benefits and risks of this medication with your doctor to ensure the best possible outcome for you and your baby.
Overdose Information
Overdose Symptoms:
- Profound diuresis (excessive urination)
- Dehydration
- Electrolyte depletion (especially hypokalemia, hyponatremia)
- Hypotension (low blood pressure)
- Circulatory collapse
- Thrombosis and embolism (due to hemoconcentration)
What to Do:
Seek immediate medical attention. Call 911 or Poison Control at 1-800-222-1222. Treatment is supportive, focusing on fluid and electrolyte replacement.
Drug Interactions
Major Interactions
- Aminoglycosides (increased ototoxicity)
- Cisplatin (increased ototoxicity)
- Lithium (decreased renal clearance of lithium, leading to toxicity)
- NSAIDs (may reduce diuretic and antihypertensive effects of torsemide)
- Digoxin (increased risk of digoxin toxicity due to hypokalemia)
- Other antihypertensives (additive hypotensive effects)
- Corticosteroids (increased risk of hypokalemia)
- Amphotericin B (increased risk of hypokalemia)
Moderate Interactions
- Probenecid (may decrease torsemide secretion)
- Salicylates (may reduce diuretic effect in patients with cirrhosis)
- Warfarin (potential for altered anticoagulant effect, monitor INR)
- Sucralfate (may reduce absorption of torsemide)
- Cholestyramine (may reduce absorption of torsemide)
- Phenytoin (may reduce diuretic effect)
Minor Interactions
- Antidiabetic agents (may decrease hypoglycemic effect)
Monitoring
Baseline Monitoring
Serum Electrolytes (Na, K, Cl, Mg, Ca)
Rationale: To establish baseline levels and identify pre-existing imbalances, as torsemide can cause electrolyte disturbances.
Timing: Prior to initiation of therapy.
Renal Function (BUN, Serum Creatinine)
Rationale: To assess baseline kidney function, as torsemide is renally eliminated and its efficacy/safety can be affected by renal impairment.
Timing: Prior to initiation of therapy.
Blood Pressure
Rationale: To establish baseline and monitor for hypotensive effects.
Timing: Prior to initiation of therapy.
Fluid Status (Weight, Edema)
Rationale: To assess baseline fluid overload and monitor response to diuretic therapy.
Timing: Prior to initiation of therapy.
Routine Monitoring
Serum Electrolytes (Na, K, Cl, Mg, Ca)
Frequency: Weekly initially, then monthly or as clinically indicated.
Target: Potassium: 3.5-5.0 mEq/L; Sodium: 135-145 mEq/L; Magnesium: 1.7-2.2 mg/dL
Action Threshold: Potassium < 3.0 mEq/L or > 5.5 mEq/L; Sodium < 130 mEq/L or > 150 mEq/L; significant changes from baseline.
Renal Function (BUN, Serum Creatinine)
Frequency: Monthly initially, then every 3-6 months or as clinically indicated.
Target: Creatinine: within patient's baseline range; BUN: within patient's baseline range.
Action Threshold: Significant increase in creatinine (>25% from baseline or >0.5 mg/dL increase) or BUN.
Blood Pressure
Frequency: Regularly, especially during dose titration.
Target: Individualized based on patient's condition (e.g., <130/80 mmHg for hypertension).
Action Threshold: Symptomatic hypotension or persistent systolic BP < 90 mmHg.
Fluid Status (Daily Weight, Edema, I&O)
Frequency: Daily (for hospitalized patients or those with significant fluid overload), then weekly for outpatients.
Target: Stable weight, reduction/resolution of edema.
Action Threshold: Rapid weight loss (>2-3 lbs/day), signs of dehydration, or persistent/worsening edema.
Symptom Monitoring
- Dizziness or lightheadedness (orthostatic hypotension)
- Muscle cramps or weakness (electrolyte imbalance, especially hypokalemia)
- Nausea, vomiting, or loss of appetite (electrolyte imbalance)
- Excessive thirst or dry mouth (dehydration)
- Increased fatigue or lethargy
- Changes in urine output (too little or too much)
- Hearing changes or ringing in ears (ototoxicity, rare but possible with high doses or co-administration of ototoxic drugs)
Special Patient Groups
Pregnancy
Torsemide is Pregnancy Category C. It should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Diuretics are generally not recommended for routine use in pregnant women with mild edema who are otherwise healthy, as they may decrease placental perfusion.
Trimester-Specific Risks:
First Trimester:
Limited data, potential for fetal harm cannot be ruled out.
Second Trimester:
Potential for decreased placental perfusion and fetal growth restriction.
Third Trimester:
Potential for decreased placental perfusion, fetal growth restriction, and neonatal electrolyte disturbances (e.g., thrombocytopenia, jaundice).
Lactation
Torsemide is excreted in breast milk. Due to the potential for serious adverse reactions in the nursing infant (e.g., electrolyte disturbances, dehydration, suppression of lactation), a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.
Infant Risk:
Moderate risk (L3) - potential for dehydration, electrolyte imbalance, and theoretical risk of ototoxicity in the infant. May also suppress lactation.
Pediatric Use
Safety and effectiveness in pediatric patients have not been established. Use is generally not recommended.
Geriatric Use
No overall differences in safety or effectiveness have been observed between elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out. Start with lower doses and titrate carefully, monitoring closely for dehydration and electrolyte imbalances, as elderly patients are more susceptible to these effects.
Clinical Information
Clinical Pearls
- Torsemide has a longer half-life and duration of action compared to furosemide, allowing for once-daily dosing.
- It has higher and more consistent oral bioavailability than furosemide, making oral dosing more predictable.
- Unlike furosemide, torsemide has a mild aldosterone antagonist effect, which may contribute to its efficacy and potentially reduce potassium loss.
- Administer in the morning to prevent nocturia.
- Monitor for signs of volume depletion (e.g., orthostatic hypotension, dizziness) and electrolyte abnormalities (especially hypokalemia, hyponatremia, hypomagnesemia).
- Patients with hepatic cirrhosis should be monitored closely for electrolyte and acid-base imbalances, and potential for hepatic encephalopathy. Concomitant use with an aldosterone antagonist is often recommended in this population.
Alternative Therapies
- Furosemide (another loop diuretic)
- Bumetanide (another loop diuretic)
- Ethacrynic acid (another loop diuretic, used in sulfa allergy)
- Thiazide diuretics (e.g., hydrochlorothiazide, chlorthalidone) for hypertension or mild edema
- Potassium-sparing diuretics (e.g., spironolactone, eplerenone, amiloride, triamterene) often used in combination with loop diuretics to counteract potassium loss.
Cost & Coverage
Average Cost:
Varies widely, typically $10-$50 per 30 tablets (20mg)
Generic Available:
Yes
Insurance Coverage:
Tier 1 or Tier 2 (Generic)
General Drug Facts
If your symptoms or health issues persist or worsen, it's essential to contact your doctor for further guidance. To ensure your safety, never share your medication with others or take someone else's medication. Some medications may come with an additional patient information leaflet, so be sure to check with your pharmacist for more information. If you have any questions or concerns about this medication, don't hesitate to reach out to your doctor, nurse, pharmacist, or other healthcare provider. In the event of a suspected overdose, immediately call your local poison control center or seek emergency medical attention. When seeking help, be prepared to provide details about the overdose, including the medication taken, the amount, and the time it occurred.