What is the dose of Torsemide (a loop diuretic)?

From the Guidelines

Torsemide should be dosed at 10-20 mg once daily for the treatment of edema associated with heart failure, as recommended by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. The initial daily dose of torsemide can be adjusted based on the patient's response and renal function.

• The maximum total daily dose of torsemide is 200 mg, as stated in the guideline 1.
• Torsemide has a longer duration of action, lasting 12-16 hours, allowing for once-daily dosing 1.
• When administering torsemide, it is essential to monitor for electrolyte imbalances, particularly hypokalemia, and adjust the dose accordingly 1.
• Patients with severe renal impairment may require higher doses to achieve the desired effect, but this should be done with caution and close monitoring of renal function and electrolyte levels 1. The 2022 AHA/ACC/HFSA guideline provides the most recent and highest quality evidence for the management of heart failure, including the use of torsemide as a loop diuretic 1.
• The guideline recommends the use of diuretics, including torsemide, to improve symptoms and reduce congestion in patients with heart failure 1.
• The recommended initial daily dose and maximum total daily dose of torsemide are based on the guideline's recommendations, which are supported by the latest evidence 1.

From the FDA Drug Label

1. 1 Treatment of Edema Edema associated with heart failure The recommended initial dose is 10 mg or 20 mg oral torsemide tablets once daily. If the diuretic response is inadequate, titrate upward by approximately doubling until the desired diuretic response is obtained. Doses higher than 200 mg have not been adequately studied Edema associated with chronic renal failure The recommended initial dose is 20 mg oral torsemide tablets once daily. If the diuretic response is inadequate, titrate upward by approximately doubling until the desired diuretic response is obtained. Doses higher than 200 mg have not been adequately studied Edema associated with hepatic cirrhosis The recommended initial dose is 5 mg or 10 mg oral torsemide tablets once daily, administered together with an aldosterone antagonist or a potassium-sparing diuretic. If the diuretic response is inadequate, titrate upward by approximately doubling until the desired diuretic response is obtained. Doses higher than 40 mg have not been adequately studied in this population.
2. 2 Treatment of Hypertension The recommended initial dose is 5 mg once daily. If the 5 mg dose does not provide adequate reduction in blood pressure within 4 to 6 weeks, increase to 10 mg once daily. If the response to 10 mg is insufficient, add another antihypertensive agent to the treatment regimen.

The recommended initial dose of torsemide varies based on the condition being treated:

• Edema associated with heart failure: 10 mg or 20 mg once daily
• Edema associated with chronic renal failure: 20 mg once daily
• Edema associated with hepatic cirrhosis: 5 mg or 10 mg once daily
• Hypertension: 5 mg once daily The dose may be titrated upward by approximately doubling until the desired diuretic response is obtained, with maximum doses of 200 mg for heart failure and chronic renal failure, and 40 mg for hepatic cirrhosis 2.

From the Research

Torsemide Dose Information

• The recommended initial adult dosage of torsemide is between 5 and 20 mg once daily orally or intravenously, depending on the indication 3.
• Torsemide can be given without regard to meals, with a bioavailability of approximately 80% and little first-pass metabolism 3.
• The serum concentration of torsemide reaches its peak within 1 hour after oral administration, and diuresis lasts approximately 6-8 hours 3.
• Special dosage adjustments in the elderly are not necessary 3.
• In trials of up to 48 weeks' duration in patients with mild to moderate essential hypertension, torsemide, administered as a single daily dose, has been shown to achieve adequate blood pressure control reaching steady-state within 8 to 12 weeks 4.
• Those patients not responding initially have generally responded to a doubling of the dose 4.

Comparison with Furosemide

• Torsemide is at least twice as potent as furosemide on a weight-for-weight basis, produces equivalent diuresis and natriuresis at lower urinary concentrations, and has a longer duration of action 4.
• Torsemide appears to promote excretion of potassium and calcium to a lesser extent than furosemide 4.
• Comparative trials of up to 6 months show torsemide is as effective as indapamide, hydrochlorothiazide, or a combination of triamterene/hydrochlorothiazide in maintaining control of blood pressure 4.
• The use of torsemide compared to furosemide did not result in statistically significant differences in all-cause mortality or rehospitalization rates 5.
• Torsemide was associated with a similar, though statistically significantly lower, risk of the composite effectiveness outcome compared with furosemide in older adults with heart failure 6.