Torsemide Dosing Recommendations
The recommended initial dose of torsemide for heart failure is 10-20 mg once daily, with titration by approximately doubling the dose until the desired diuretic response is obtained, up to a maximum of 200 mg daily. 1
Dosing by Indication
Heart Failure
- Initial dose: 10-20 mg once daily 2, 1
- Titration: If inadequate response, double the dose until desired effect achieved
- Maximum daily dose: 200 mg 1
- Duration of action: 12-16 hours 2, 3
Chronic Renal Failure
- Initial dose: 20 mg once daily 1
- Titration: Double dose if inadequate response
- Maximum daily dose: 200 mg 1
Hepatic Cirrhosis
- Initial dose: 5-10 mg once daily 1
- Must be administered with an aldosterone antagonist or potassium-sparing diuretic
- Maximum daily dose: 40 mg 1
Hypertension
- Initial dose: 5 mg once daily 1
- If inadequate response after 4-6 weeks, increase to 10 mg once daily
- If still insufficient, add another antihypertensive agent 1
Conversion from Furosemide
When switching patients from furosemide to torsemide, use the following conversion ratio (4:1) 3:
| Furosemide Dose (mg) | Torsemide Dose (mg) |
|---|---|
| 20 mg | 5 mg |
| 40 mg | 10 mg |
| 80 mg | 20 mg |
| 120 mg | 30 mg |
| 160 mg | 40 mg |
Advantages of Torsemide
Torsemide offers several advantages over other loop diuretics:
- Higher oral bioavailability (approximately 80%) compared to furosemide (variable 10-100%) 3, 4
- Longer duration of action (12-16 hours vs. 6-8 hours for furosemide) 2, 3
- More predictable absorption regardless of food intake 5
- Once-daily dosing due to longer half-life (3-4 hours) 6, 5
Monitoring and Titration
- Assess diuretic response through:
- Daily weight measurements
- Improvement in signs/symptoms of congestion
- Urine output
- Monitor serum electrolytes (particularly potassium, sodium, chloride)
- Check renal function regularly
- Titrate to achieve euvolemia with the lowest effective dose 3
Clinical Pearls and Pitfalls
- Bioavailability advantage: Unlike furosemide, torsemide has high and consistent bioavailability, making oral and intravenous doses therapeutically equivalent 5
- Potassium considerations: Torsemide may produce less kaliuresis than equivalent doses of furosemide, potentially reducing the risk of hypokalemia 7
- Diuretic resistance: If patients become unresponsive to high doses, consider:
- Evaluating sodium intake
- Checking for NSAID use (which can block diuretic effects)
- Assessing renal function 2
- Combination therapy: For resistant edema, consider combining loop and thiazide diuretics with careful monitoring 3
- Avoid in angioedema: As with other medications affecting the renin-angiotensin system, use caution in patients with history of angioedema 2
Torsemide's pharmacokinetic profile makes it an excellent choice for patients requiring diuretic therapy, particularly those who may benefit from once-daily dosing or have variable absorption issues with other loop diuretics.