====== Torsemide (Demadex®) ======<WRAP right 340px><WRAP infobox>| | {{ :cardio:diuretics:torsemide_structure.svg |}} |^ Torsemide || Brand Names | Demadex® || Drug Class | [[cardio:diuretics:loop:start|Loop Diuretic]] || Primary Indications | [[cardio:heart_failure:start|Heart Failure]]; Edema; Hypertension (selected) || Blood Pressure Effect | ↓ preload, ↓ BP || Mortality Benefit | No (symptom relief) || Elimination | Hepatic & renal || Black Box Warning | Ototoxicity (high dose/rapid IV) || FDA Approval | 1993 |</WRAP></WRAP>===== Overview =====Torsemide is a loop diuretic that blocks NKCC2 in the thick ascending limb, producing potent diuresis. It has better oral bioavailability and longer duration than furosemide.<WRAP clear></WRAP>----===== Mechanism of Action =====**Primary Molecular Target**  * Na-K-2Cl cotransporter (NKCC2) in thick ascending limb**Segment Effects**  * ↓ NaCl reabsorption in TAL  * ↑ Ca2+ and Mg2+ excretion  * Disrupts medullary concentrating gradient**Net Physiologic Outcomes**  * Powerful diuresis  * ↓ preload and congestion  * Longer duration vs furosemide----===== Indications =====  * Heart failure with congestion  * Edema from CKD/cirrhosis  * Hypertension with volume overload----<WRAP blackbox>===== Black Box Warning =====Risk of profound diuresis and electrolyte depletion; ototoxicity with high doses/rapid IV.</WRAP>----<WRAP contra>===== Contraindications =====Absolute:  * AnuriaRelative / Caution:  * Hypovolemia  * Severe electrolyte depletion  * Gout</WRAP>----<WRAP details>===== Dosing =====Heart failure/edema:  * PO: 10–20 mg daily (titrate)  * Typical range: 10–200 mg/dayRenal adjustment:  * Higher doses may be required in CKD</WRAP>----<WRAP details>===== Pharmacokinetics =====Absorption:  * Oral/IVBioavailability:  * ~80–90%Metabolism:  * Hepatic (CYP2C9)Half-life:  * ~3–4 hoursElimination:  * Hepatic & renal</WRAP>----<WRAP details>===== Adverse Effects =====Common:  * Hypokalemia  * Hypomagnesemia  * Hypotension  * PolyuriaSerious:  * Ototoxicity  * AKI from overdiuresis  * Hyponatremia</WRAP>----<WRAP details>===== Drug Interactions =====Increased risk:  * Digoxin toxicity (via hypokalemia)  * NSAIDs (↓ effect)  * Lithium (↑ levels)Avoid combination:  * Aminoglycosides (ototoxicity risk)</WRAP>----<WRAP monitoring>===== Monitoring =====Labs:  * Electrolytes (K+, Mg2+, Na+)  * CreatinineVitals:  * Blood pressure  * WeightClinical:  * Volume status  * Hearing changes (high dose)</WRAP>----<WRAP pearls>===== Clinical Pearls =====  * More predictable absorption than furosemide  * Longer duration (once-daily in many)  * Useful in diuretic resistance</WRAP>----===== Comparison Within Class =====Compared to other [[cardio:diuretics:loop:start|loop diuretics]]:  * Longer half-life than furosemide  * Higher oral bioavailability  * Less dose variability----===== Related =====  * [[cardio:diuretics:loop:start|Loop Diuretics]]  * [[cardio:heart_failure:start|Heart Failure]]  * [[cardio:diuretics:start|Diuretics]]