Demadex
torsemide (torasemide (UK))
Pharmacologic class: Loop diuretic
Therapeutic class: Diuretic, antihypertensive
Pregnancy risk category B
Action
Inhibits sodium and chloride reabsorption from ascending loop of Henle and distal renal tubule; increases renal excretion of water, sodium, chloride, magnesium, calcium, and hydrogen. Also may exert renal and peripheral vasodilatory effects. Net effect is natriuretic diuresis.
Availability
Injection: 10 mg/ml
Tablets: 5 mg, 10 mg, 20 mg, 100 mg
Indications and dosages
➣ Heart failure
Adults: 10 to 20 mg P.O. or I.V. daily. If response inadequate, double dosage until desired response occurs. Don't exceed 200 mg as a single dose.
➣ Hypertension
Adults: 5 mg P.O. daily. May increase to 10 mg daily after 4 to 6 weeks; if drug still isn't effective, additional antihypertensives may be prescribed.
➣ Chronic renal failure
Adults: 20 mg P.O. or I.V. daily. If response inadequate, double dosage until desired response occurs. Don't exceed 200 mg as a single dose.
➣ Hepatic cirrhosis
Adults: 5 or 10 mg P.O. or I.V. daily, given with aldosterone antagonist or potassium-sparing diuretic. If response inadequate, double dosage. Don't exceed 40 mg as a single dose.
Contraindications
• Hypersensitivity to drug, thiazides, or sulfonylureas
• Anuria
Precautions
Use cautiously in:
• severe hepatic disease accompanied by cirrhosis or ascites, preexisting uncorrected electrolyte imbalances, diabetes mellitus, worsening azotemia
• elderly patients
• pregnant or breastfeeding patients
• children younger than age 18.
Administration
• Give I.V. by direct injection over at least 2 minutes or by continuous I.V. infusion.
• Flush I.V. line with normal saline solution before and after administering.
Adverse reactions
CNS: dizziness, headache, asthenia, insomnia, nervousness, syncope
CV: hypotension, ECG changes, chest pain, volume depletion, atrial fibrillation, ventricular tachycardia, shunt thrombosis
EENT: rhinitis, sore throat
GI: nausea, diarrhea, vomiting, constipation, dyspepsia, anorexia, rectal bleeding, GI hemorrhage
GU: excessive urination
Metabolic: hyperglycemia, hyperuricemia, hypokalemia
Musculoskeletal: joint pain, myalgia
Respiratory: increased cough
Skin: rash
Other: edema
Interactions
Drug-drug. Aminoglycosides, cisplatin: increased risk of ototoxicity
Amphotericin B, corticosteroids, mezlocillin, piperacillin, potassium-wasting diuretics, stimulant laxatives: additive hypokalemia
Antihypertensives, nitrates: additive hypotension
Lithium: increased lithium blood level and toxicity
Neuromuscular blockers: prolonged neuromuscular blockade
Nonsteroidal anti-inflammatory drugs, probenecid: inhibited diuretic response
Sulfonylureas: decreased glucose tolerance, hyperglycemia in patients with previously well-controlled diabetes
Drug-diagnostic tests. Glucose, uric
acid: increased levels
Potassium: decreased level
Drug-herbs. Dandelion: interference with diuresis
Ephedra (ma huang): reduced hypotensive effect of torsemide
Geranium, ginseng: increased risk of diuretic resistance
Licorice: rapid potassium loss
Drug-behaviors. Acute alcohol ingestion: additive hypotension
Patient monitoring
• Monitor vital signs, especially for hypotension.
• Assess ECG for arrhythmias and other changes.
• Monitor weight and fluid intake and output to assess drug efficacy.
• Monitor electrolyte levels, particularly potassium. Stay alert for signs and symptoms of hypokalemia.
• Assess hearing for signs and symptoms of ototoxicity.
• Monitor blood glucose level carefully in diabetic patient.
Patient teaching
• Advise patient to take in morning with or without food.
• Instruct patient to move slowly when sitting up or standing, to avoid dizziness from sudden blood pressure drop.
• Tell patient to monitor weight and report sudden increases.
• Instruct diabetic patient to monitor blood glucose level carefully.
• Caution patient to avoid alcohol during drug therapy.
• Advise patient to consult prescriber before using herbs.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, herbs, and behaviors mentioned above.
torsemide
(tore-se-mide) torsemide,Demadex
(trade name)Classification
Therapeutic: antihypertensivesPharmacologic: loop diuretics
Indications
- HF,
- Hepatic or renal disease.
Action
Therapeutic effects
Pharmacokinetics
Time/action profile (diuretic effect)
| ROUTE | ONSET | PEAK | DURATION |
|---|---|---|---|
| PO | within 60 min | 60–120 min | 6–8 hr |
| IV | within 10 min | within 60 min | 6–8 hr |
Contraindications/Precautions
Adverse Reactions/Side Effects
Central nervous system
- dizziness
- headache
- nervousness
Ear, Eye, Nose, Throat
- hearing loss
- tinnitus
Cardiovascular
- hypotension
Gastrointestinal
- constipation
- diarrhea
- dry mouth
- dyspepsia
- nausea
- vomiting
Genitourinary
- ↑ BUN
- excessive urination
Dermatologic
- stevens-johnson syndrome (life-threatening)
- toxic epidermal necrolysis (life-threatening)
- photosensitivity
- rash
Endocrinologic
- hyperglycemia
- hyperuricemia
Fluid and Electrolyte
- dehydration (most frequent)
- hypocalcemia
- hypochloremia (most frequent)
- hypokalemia (most frequent)
- hypomagnesemia (most frequent)
- hyponatremia (most frequent)
- hypovolemia (most frequent)
- metabolic alkalosis (most frequent)
Musculoskeletal
- arthralgia
- muscle cramps
- myalgia
Interactions
Drug-Drug interaction
↑ hypotension with antihypertensives, nitrates, or acute ingestion of alcohol.↑ risk of hypokalemia with other diuretics, amphotericin B, stimulant laxatives, and corticosteroids.Hypokalemia may ↑ risk of digoxin toxicity and ↑ risk of arrhythmia in patients taking drugs that prolong the QT interval.May ↑ risk of lithium toxicity.↑ risk of ototoxicity with aminoglycosides.NSAIDS may ↓ effects.↑ risk of salicylate toxicity (with use of high-dose salicylate therapy).Cholestyramine may ↓ absorption.Route/Dosage
HFAvailability (generic available)
Nursing implications
Nursing assessment
- Assess fluid status during therapy. Monitor daily weight, intake and output ratios, amount and location of edema, lung sounds, skin turgor, and mucous membranes. Notify health care provider if thirst, dry mouth, lethargy, weakness, hypotension, or oliguria occurs.
- Monitor BP and pulse before and during administration. Monitor frequency of prescription refills to determine adherence in patients treated for hypertension.
- Assess patients receiving digoxin for anorexia, nausea, vomiting, muscle cramps, paresthesia, and confusion. Patients taking digoxin are at increased risk of digoxin toxicity due to potassium-depleting effect of the diuretic. Potassium supplements or potassium-sparing diuretics may be used concurrently to prevent hypokalemia.
- Assess patient for tinnitus and hearing loss. Audiometry is recommended for patients receiving prolonged high-dose IV therapy. Hearing loss is most common following rapid or high-dose IV administration in patients with decreased renal function or those taking other ototoxic drugs.
- Assess for allergy to sulfonamides.
- Assess patient for skin rash frequently during therapy. Discontinue torsemide at first sign of rash; may be life-threatening. Stevens-Johnson syndrome or toxic epidermal necrolysis may develop. Treat symptomatically; may recur once treatment is stopped.
- Geriatric: Diuretic use is associated with increased risk for falls in older adults. Assess falls risk and implement fall prevention strategies.
- Lab Test Considerations: Monitor electrolytes, renal and hepatic function, serum glucose, and uric acid levels before and periodically during therapy. May cause ↓ serum sodium, potassium, calcium, and magnesium concentrations. May also cause ↑ BUN, serum glucose, creatinine, and uric acid levels.
Potential Nursing Diagnoses
Excess fluid volume (Indications)Risk for deficient fluid volume (Side Effects)
Implementation
- Administer medication in the morning to prevent disruption of sleep cycle.
- IV is preferred over IM for parenteral administration.
- Oral: May be taken with food or milk to minimize gastric irritation.
Intravenous Administration
- Diluent: Administer undiluted.Concentration: 10 mg/mL.
- Rate: Administer slowly over 2 min.
- May also be administered as a continuous infusion.
- Y-Site Compatibility: milrinone, nesiritide
Patient/Family Teaching
- Instruct patient to take torsemide as directed. Take missed doses as soon as possible; do not double doses.
- Caution patient to change positions slowly to minimize orthostatic hypotension. Caution patient that the use of alcohol, exercise during hot weather, or standing for long periods during therapy may enhance orthostatic hypotension.
- Instruct patient to consult health care professional regarding a diet high in potassium (see ).
- Advise patient to contact health care professional if they gain more than 2–3 lb/day.
- Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking any OTC medications concurrently with this therapy.
- Instruct patient to notify health care professional of medication regimen prior to treatment or surgery.
- Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions.
- Advise patient to contact health care professional immediately if rash muscle weakness, cramps, nausea, dizziness, numbness, or tingling of extremities occurs.
- Advise diabetic patients to monitor blood glucose closely; may cause increased blood glucose levels.
- Emphasize the importance of routine follow-up examinations.
- Hypertension: Advise patients on antihypertensive regimen to continue taking medication even if feeling better. Torsemide controls but does not cure hypertension.
- Reinforce the need to continue additional therapies for hypertension (weight loss, exercise, restricted sodium intake, stress reduction, regular exercise, moderation of alcohol consumption, cessation of smoking).
Evaluation/Desired Outcomes
- Decrease in edema.
- Decrease in abdominal girth and weight.
- Increase in urinary output.
- Decrease in BP.