Torsemide vs Furosemide: Heart Failure Medications Compared

Torsemide vs Furosemide Overview

Torsemide and furosemide are prescription drugs that are FDA-approved for use in heart failure patients. They are diuretics (water pills) that help the body get rid of excess fluid and salt. This article will describe the key similarities and differences between torsemide and furosemide.

What is Torsemide?

Torsemide belongs to the class of medications called loop diuretics. It is used to treat edema (fluid retention) caused by heart failure, kidney disease, and liver disease. Torsemide comes in the form of a tablet to take by mouth once daily. The generic drug torsemide is also available under the brand name Demadex.

What is Furosemide?

Furosemide is also a loop diuretic. It is widely prescribed, alone or with other medications, to treat hypertension (high blood pressure). Doctors also use furosemide to treat edema (buildup of fluid in the body) in people with kidney, liver, and heart disease, including acute and chronic heart failure patients. Furosemide comes as a tablet and liquid solution to take by mouth 1-2 times a day. The generic drug furosemide is also available under the brand name Lasix. 

Note: Intravenous formulations for injection into a vein are also available for both furosemide and torsemide for use in healthcare settings. 

Pharmacokinetics and Pharmacodynamics: How Do They Work?

Loop diuretics such as torsemide and furosemide work by preventing the reabsorption of sodium and water in the kidneys. This results in the removal of excess fluid and salt from the body through urine, thereby reducing edema (fluid buildup in the body). 

Torsemide is usually taken once daily because it has a longer half-life (it stays in the body longer). Furosemide has a more rapid onset of action (it works faster) compared to torsemide. Therefore, furosemide is used to treat acute fluid retention and alleviate symptoms quickly. Torsemide may be preferred for the convenience of once-daily dosing.

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Effectiveness in Treating Heart Failure: Torsemide vs Furosemide

Which is Better: Torsemide versus Furosemide?

There is insufficient evidence to say if torsemide is better (more effective or safer) than furosemide in patients with symptomatic heart failure. In other words, the available evidence from systematic reviews and meta-analysis of studies suggests that furosemide and torsemide are equally effective in improving the clinical status of patients with heart failure, including both chronic heart failure and acute heart failure. 

Effectiveness in Symptom Management

Research suggests torsemide is a high-ceiling drug and long-acting loop diuretic. Follow-up data collection has found that torsemide may be up to 8 times more potent than furosemide with a longer-lasting diuretic effect and more potassium-sparing abilities than furosemide.

Observational data suggests torsemide improved outcomes in surrogate markers of heart failure severity, such as left ventricular function, plasma brain natriuretic peptide levels, and the New York Heart Association class (NYHA class).

Patient Quality of Life Outcomes

Researchers have found that among predefined subgroups of patients with reduced, mildly reduced, or preserved ejection fraction, hospitalizations are similar in patients taking torsemide and patients taking furosemide. Studies have measured five secondary outcomes with all-cause mortality or all-cause hospitalization and total hospitalizations over 12 months. In patients post hospital discharge for heart failure, the use of torsemide compared to furosemide did not show a notable difference in all-cause mortality. 

Clinical Trials and Research Findings

The Transform HF Trial

Published in 2023, the Transform HF trial measured a primary outcome of all-cause mortality in patients discharged after hospitalization for heart failure. The trial found that compared to furosemide, torsemide did not result in a difference that would be considered statistically significant in terms of all-cause mortality over a median follow-up of 12 months. However, the interpretation of the trial findings was limited by nonadherence and loss of follow-up.

Other Key Cardiovascular Medicine Studies Comparing Torsemide and Furosemide

The Duke Clinical Research Institute at Duke University Medical Center conducted a pragmatic randomized trial and found that torsemide use was not associated with reduced all-cause mortality after risk adjustment. In this trial, torsemide was given intravenously to eligible patients who were hospitalized. However, this method of administration is only applicable to some patients and is not effective in all patients. 

Another randomized clinical trial found that patients in the torsemide group had greater improvements in functioning and reduction in social limitations as well as decreased mortality compared to the furosemide group. In addition, many previous randomized clinical trials and prior observational data suggest that torsemide may be superior to furosemide in terms of improving clinical outcomes and reducing the number of patients hospitalized for heart failure. 

However, studies suggest that while torsemide use may initially be associated with survival benefits compared to furosemide, after risk adjustment, there is no significant difference in mortality rates between the two drugs for acute decompensated heart failure or chronic heart failure. 

When to Switch from Furosemide to Torsemide?

Your healthcare provider may recommend switching from Lasix (furosemide) to Demadex (torsemide) if the desired clinical outcomes are not achieved with Lasix. Meaning, that if your heart failure symptoms are not controlled on Lasix (furosemide), your doctor may try you on Demadex (torsemide). 

Preclinical and clinical data in patients recently hospitalized with heart failure also suggest potential benefits of torsemide versus furosemide in terms of increased bioavailability, longer half-life (drug effect stays for longer in the body), and beneficial effects on myocardial fibrosis, ventricular remodeling, sympathetic activation, aldosterone production, and natriuretic peptides. Your doctor may make a switch based on guideline-directed factors and the patient's clinical presentation. In some cases, healthcare resource utilization may be a contributing factor, such as with a national shortage of certain medications. 

Remember, both furosemide and torsemide are loop diuretics used to manage edema (fluid overload) in heart failure patients, but torsemide has been shown to be a stronger drug. Because torsemide is a more potent loop diuretic, it may also come with more or stronger side effects. You and your doctor can work together to determine the best drug and dose based on symptom control and side effects.

Torsemide vs Furosemide: Safety Profile and Side Effects

Common Side Effects of Torsemide

• Dizziness

• Vomiting

• Headache

• Electrolyte imbalances such as hypokalemia (low potassium), hyponatremia (low sodium), and hypomagnesemia (low magnesium)

• Cardiac arrhythmias 

• Muscle weakness

• Excessive urination

• Dehydration (signs may include dry mouth and increased thirst)

• Low blood pressure (symptoms may include fainting and loss of consciousness)

• Elevated blood uric acid levels and acute gout attacks due to excessive loss of fluids from the body 

• Allergic reactions (rash, itching, hives)

Common Side Effects of Furosemide

• Electrolyte imbalances

• Dehydration

• Hypotension (low blood pressure)

• Elevated blood uric acid levels

• Ototoxicity: Furosemide can damage the inner ear and cause hearing problems or tinnitus (ringing in the ears) - this side effect is rare 

• Allergic reactions (rash, itching, hives)

Safety Profile of Torsemide versus Furosemide

Both torsemide and furosemide work in a similar way and therefore have a similar safety profile. Both drugs are generally well-tolerated if used as prescribed. Risks include electrolyte disturbances, dehydration, and low blood pressure. Regular monitoring of blood pressure and electrolyte levels is therefore necessary during treatment.

Because furosemide has a shorter duration of action compared to torsemide, furosemide requires more frequent dosing. The longer duration of action of torsemide compared with furosemide allows less frequent dosing, which is convenient for patients. But because torsemide stays in the system longer, it carries a higher risk of accumulating in the body and causing toxicity, 

Ototoxicity (ear damage) is a rare complication in patients taking furosemide. This drug should be used with caution in older adults who are at a higher risk of ear damage.

Torsemide and Kidney Health: Is Torsemide Bad For Your Kidneys?

Torsemide can be bad for your kidneys because it can lead to diuresis (excessive fluid loss, dehydration, hypovolemia (reduced blood volume), electrolyte abnormalities, and low blood pressure, which can affect kidney function. Regular and close monitoring of kidney function and electrolyte levels is therefore necessary to identify and treat acute kidney injury or severe electrolyte abnormalities in patients taking torsemide. 

Dosage and Administration Guidelines

The recommended doses for torsemide and furosemide and considerations for administration are based on the patient’s age, condition, and treatment goals. 

Recommended Dosages for Torsemide

For edema:

• The typical starting dose of torsemide in adults is 20 milligrams (mg) to 100 mg once daily. For patients who are naive to loop diuretics, it is lower, at 10 mg to 20 mg daily.

• This dose may be increased depending on the severity of edema (swelling) and response. 

For hypertension:

• The usual starting dose is 5 mg once daily of torsemide.

• If necessary, to achieve blood pressure control, the torsemide dose can be increased to 10 mg daily.

• Dose adjustment is necessary for pediatric patients and patients with chronic kidney disease.

Recommended Dosages for Furosemide

For edema and congestive heart failure:

• Starting furosemide dose in adults is typically 20 mg to 80 mg daily given in 1-2 divided doses. For patients who are naive to loop diuretics, 20 mg to 40 mg initially is recommended.

• Higher doses may be needed in acute conditions such as pulmonary edema. 

For hypertension:

• The usual starting dose of furosemide for high blood pressure in adults is 20 mg to 40 mg twice daily.

• Doses for specific populations, such as pediatric patients or patients with renal compromise are decided by the healthcare provider.

Considerations for Administration

• Oral furosemide and torsemide can be taken with or without food. 

• Diuretics (water pills) are usually taken in the daytime to reduce night awakenings and frequent urination which can affect sleep quality.

• Intravenous (IV) administration of diuretics can be done in a hospital setting under medical supervision.

• Regular monitoring of fluid balance, vital signs, and electrolyte levels is essential in patients with heart failure, renal disease, or other conditions during diuretic use.

Patient Considerations

It is important to take torsemide or furosemide exactly as prescribed by your doctor. You should report any unusual symptoms or side effects after starting therapy. Do not try to adjust the dose of your medicine without medical supervision. Remember, diuretics are used as part of a comprehensive treatment plan with other drugs for both high blood pressure and fluid overload in congestive heart failure. They can cause serious side effects and should only be taken under the supervision of a healthcare professional.

Special Populations

• Pediatric Patients: Torsemide and furosemide can be used in children, but dosage adjustments are needed based on the child’s body weight and kidney function. 

• Elderly Patients: Older adults are more sensitive to loop diuretic therapy and are at an increased risk of adverse reactions. Elderly patients should therefore make sure they are taking the correct dose and should be closely monitored for electrolyte imbalances.

• Patients with Kidney Disease: Both torsemide and furosemide are eliminated from the body by the kidneys. Kidney impairment (reduced kidney function) can affect the excretion of these drugs, resulting in accumulation of the drugs in the body. Patients with renal dysfunction are given lower doses according to their renal function to lower the risk of toxicity. 

• Pregnant and Nursing Women: The risk-benefit hazard ratio is carefully considered before giving loop diuretics like torsemide or furosemide to pregnant or breastfeeding women. These medications may have harmful effects on the baby. 

Tolerability and Adherence

• Tolerability: Preclinical and clinical data suggest that both drugs, furosemide and torsemide, are generally well tolerated. However, electrolyte disturbances can occur. Tell your doctor if you develop any severe side effects after starting treatment with a loop diuretic. 

• Adherence: Patients with hypertension or heart failure are often on multiple drugs, including diuretics, to improve clinical outcomes. This can lead to poor adherence to treatment. To get the maximum benefits from loop diuretic drugs, take them regularly as prescribed.

Monitoring and Follow-Up

Regular monitoring is essential by the patient’s usual outpatient clinicians while on torsemide or furosemide for heart failure. This includes:

• Regular assessment of fluid intake, urine output, and changes in body weight to monitor fluid going in and out.

• Periodic blood tests to monitor electrolyte levels. Electrolyte disturbances in sodium, potassium, and magnesium can lead to serious health disturbances such as cardiac arrhythmias.

• Regular monitoring of systolic blood pressure and diastolic blood pressure, especially in patients being treated for hypertension, to prevent hypotension. 

• Regular follow-up appointments with healthcare providers for continued assessment, dosage adjustments, and monitoring for adverse effects.

Cost Comparison and Insurance Coverage

• Both torsemide and furosemide are available in low-cost generic forms.  Generic drugs are usually priced considerably lower than the brand names and are equally effective and safe.

• The two loop diuretics furosemide and torsemide are covered by most private health insurance plans as well as Medicare/Medicaid, but coverage for prescription drugs can vary from plan to plan. 

• Talk to your healthcare provider or pharmacist to explore cost-saving options such as free samples. A BuzzRx savings card can help you access prescribed medication at a lower cost.

What Is Heart Failure?

Congestive heart failure, commonly known as heart failure, is a chronic medical condition that affects millions of people worldwide. In people with this condition, the pumping ability of the heart muscle is decreased. This results in decreased oxygen delivery to the organs in the body. Heart failure can cause symptoms such as shortness of breath, fatigue, and swelling in the extremities.

Types of Heart Failure

There are two main types of heart failure - systolic heart failure and diastolic heart failure. 

In systolic heart failure, the left ventricle of the heart is unable to contract and pump blood effectively. This is called reduced ejection fraction (HFrEF) heart failure. In diastolic heart failure, the left ventricle becomes stiff and has trouble relaxing between beats, making it harder to fill with blood. This is called preserved ejection fraction (HFpEF) heart failure.

Treatment of heart failure with medications can increase the lifespan and quality of life of affected individuals. 

Types of Heart Failure Medications

Many types of medications are used to treat heart failure patients. Diuretics (water pills) like furosemide and torsemide are commonly used to manage heart failure. They reduce fluid retention, which is one of the main symptoms of heart failure. These diuretic medications reduce edema and lower blood pressure by helping the body remove excess salt and water. Therefore, diuretics work by reducing the workload of the heart.

Diuretics are considered a first-line treatment for heart failure. They offer rapid relief from swelling, shortness of breath, and fatigue. Different types and brands of diuretics are available with advantages and disadvantages.

How Are Furosemide and Torsemide Similar?

Both torsemide and furosemide belong to the same class of medications called loop diuretics. They both cause diuresis (removal of excess fluid from the body) and are used to treat edema in heart failure patients. 

Key Differences: Furosemide vs Torsemide 

Frequently Asked Questions

Why Is Torsemide Preferred Over Furosemide?

Torsemide is sometimes preferred over furosemide in some patient populations due to its longer duration of action, less frequent dosing requirement, and potential advantages in efficacy and potassium-sparing. However, torsemide is not always the best choice. Your doctor will choose a loop diuretic strategy based on a number of factors.

What Is A Stronger Diuretic Than Furosemide?

Diuretics such as torsemide and bumetanide are considered stronger than furosemide in some aspects. Studies show that compared to furosemide, torsemide is more potent and has a longer-lasting diuretic effect.