What is the recommended use and dosage of Torsemide (torasemide) for treating edema?

Torsemide for Treating Edema

Torsemide is recommended for treating edema associated with heart failure at an initial dose of 10-20 mg once daily, with titration up to 200 mg daily if needed, based on clinical response. 1

Dosing Recommendations by Condition

Heart Failure Edema

• Initial dose: 10-20 mg orally once daily 2, 1
• Maximum dose: Up to 200 mg daily 1
• Duration of action: 12-16 hours 2
• Advantage: Longer duration of action compared to other loop diuretics (furosemide: 6-8 hours, bumetanide: 4-6 hours) 2, 3

Chronic Renal Failure Edema

• Initial dose: 20 mg orally once daily 1
• Maximum dose: Up to 200 mg daily 1

Hepatic Cirrhosis Edema

• Initial dose: 5-10 mg orally once daily 1
• Maximum dose: Up to 40 mg daily 1
• Important: Should be administered with an aldosterone antagonist or potassium-sparing diuretic 1

Clinical Benefits of Torsemide

• Better bioavailability: ~80% bioavailability with little first-pass metabolism 4, 5
• Reliable absorption: More consistent absorption than furosemide in heart failure patients with gut wall edema 3
• Convenient dosing: Once-daily administration due to longer duration of action 5
• Equivalent potency: 10-20 mg torsemide is approximately equivalent to 40 mg furosemide 6

Monitoring and Adjustments

1. Initial response assessment:

   • Monitor urine output, especially in the first hours of treatment
   • For hospitalized patients, consider bladder catheterization to accurately track output 2

2. Follow-up monitoring:

   • Assess weight, edema, and symptoms within 3-7 days
   • Check electrolytes, BUN, and creatinine within 1 week 3
   • Watch for hypokalaemia, hyponatraemia, and hyperuricaemia 2

3. Dose adjustment:

   • If diuretic response is inadequate, approximately double the dose until desired response 1
   • Total daily dose should remain <100 mg in first 6 hours and <240 mg in first 24 hours when treating acute heart failure 2

Management of Diuretic Resistance

For patients with refractory edema, consider:

• Sequential nephron blockade: Combine torsemide with thiazide diuretics 2
• Potassium-sparing combination: Add spironolactone 25-50 mg daily 2

Potential Adverse Effects

• Orthostatic hypotension, fatigue, dizziness 4, 7
• Electrolyte disturbances (less kaliuresis than furosemide) 8
• Hypovolaemia and dehydration if dosed too aggressively 2
• Neurohormonal activation 2
• May increase hypotension following initiation of ACE inhibitors/ARBs 2

Clinical Pearls

• Torsemide may be particularly beneficial in patients who have poor response to furosemide due to its better bioavailability and longer duration of action 3
• At low doses (2.5-5 mg/day), torsemide has minimal effects on plasma renin activity and aldosterone release 8
• Oral and intravenous doses are therapeutically equivalent due to high bioavailability 5
• In comparative studies, 20 mg torsemide was more effective than 40 mg furosemide in reducing body weight and improving symptoms of heart failure 6