1/15
Why is torsemide my preferred loop diuretic when treating heart failure?
As a follow-up to a recent tweetorial on furosemide and gut edema, let me offer a 3-part ode to torsemide.
Why is torsemide my preferred loop diuretic when treating heart failure?
As a follow-up to a recent tweetorial on furosemide and gut edema, let me offer a 3-part ode to torsemide.
2/
It's worth noting up-front that torsemide is NOT the most commonly used loop diuretic.
In a study of 274,515 patients diagnosed with heart failure, the discharge loop diuretics were:
➤ Furosemide 87%
➤ Bumetanide 3%
➤ Torsemide 0.4%
➤ Combo 10%
t.ly/7qZo
It's worth noting up-front that torsemide is NOT the most commonly used loop diuretic.
In a study of 274,515 patients diagnosed with heart failure, the discharge loop diuretics were:
➤ Furosemide 87%
➤ Bumetanide 3%
➤ Torsemide 0.4%
➤ Combo 10%
t.ly/7qZo
3/
A more recent poll (conducted today!) confirms the dominance of furosemide.
So there is a lot of work needed to convert folks to torsemide. My argument has 3 parts.
A more recent poll (conducted today!) confirms the dominance of furosemide.
So there is a lot of work needed to convert folks to torsemide. My argument has 3 parts.
https://twitter.com/tony_breu/status/1479169109162143762?s=20
4/
A 2001 open-label RCT looked at torsemide vs furosemide in 234 patients hospitalized with a history of heart failure. At 1 year, ≥1 readmission occurred in:
➤ 17% on torsemide
➤ 32% on furosemide
Torsemide patients were also less fatigued.
t.ly/yzDI
A 2001 open-label RCT looked at torsemide vs furosemide in 234 patients hospitalized with a history of heart failure. At 1 year, ≥1 readmission occurred in:
➤ 17% on torsemide
➤ 32% on furosemide
Torsemide patients were also less fatigued.
t.ly/yzDI
5/
TORIC was an open-label, non-randomized, post-marketing surveillance trial of 1377 patients with heart failure. Those who received torsemide had...
➤ ↓ mortality
➤ Improved heart failure class
...when compared with other loop diuretics.
t.ly/cgcg
TORIC was an open-label, non-randomized, post-marketing surveillance trial of 1377 patients with heart failure. Those who received torsemide had...
➤ ↓ mortality
➤ Improved heart failure class
...when compared with other loop diuretics.
t.ly/cgcg
7/
The ongoing TRANSFORM-HF should provide a more definitive answer.
This study is randomizing patients hospitalized with heart failure to torsemide or furosemide prior to discharge. It aims to enroll 6000 patients and be completed by August 2022.
clinicaltrials.gov/ct2/show/NCT03…
The ongoing TRANSFORM-HF should provide a more definitive answer.
This study is randomizing patients hospitalized with heart failure to torsemide or furosemide prior to discharge. It aims to enroll 6000 patients and be completed by August 2022.
clinicaltrials.gov/ct2/show/NCT03…
8/
Assuming the evidence favors torsemide, what explains the difference? At least 2 things may be contributing:
(1) Torsemide has preferred pharmacokinetics/dynamics
(2) Torsemide may be more than just a loop diuretic
Assuming the evidence favors torsemide, what explains the difference? At least 2 things may be contributing:
(1) Torsemide has preferred pharmacokinetics/dynamics
(2) Torsemide may be more than just a loop diuretic
9/
Here is a comparison of three common loop diuretics.
Items in green are "wins" for a particular diuretic.
Here is a comparison of three common loop diuretics.
Items in green are "wins" for a particular diuretic.
10/
There are a few key differences favoring torsemide:
➤ More reliable oral bioavailability
➤ Longer duration of action, allowing for daily dosing
Also, if one factors in daily versus BID dosing, the cost of torsemide is no different than furosemide.
t.ly/IDtk
There are a few key differences favoring torsemide:
➤ More reliable oral bioavailability
➤ Longer duration of action, allowing for daily dosing
Also, if one factors in daily versus BID dosing, the cost of torsemide is no different than furosemide.
t.ly/IDtk
11/
There is evidence suggesting that torsemide blocks aldosterone receptors. Supporting this is a study showing...
↑ Plasma renin
↑ Aldosterone
...in those receiving torsemide, but not those receiving furosemide.
t.ly/Bklq
There is evidence suggesting that torsemide blocks aldosterone receptors. Supporting this is a study showing...
↑ Plasma renin
↑ Aldosterone
...in those receiving torsemide, but not those receiving furosemide.
t.ly/Bklq
12/
Aldosterone antagonism may explain another finding of the study in tweet 5. Here's how many patients required potassium supplementations:
➤ Torsemide 3%
➤ Other loop diuretics 30%
t.ly/cgcg
Aldosterone antagonism may explain another finding of the study in tweet 5. Here's how many patients required potassium supplementations:
➤ Torsemide 3%
➤ Other loop diuretics 30%
t.ly/cgcg
13/
Aldosterone may play a role in myocardial fibrosis. If torsemide blocks aldosterone activity it may also have anti-fibrotic effects.
This is supported by a study showing a ↓ in serum carboxyl-terminal peptide of procollagen type I with torsemide.
t.ly/Vg6f
Aldosterone may play a role in myocardial fibrosis. If torsemide blocks aldosterone activity it may also have anti-fibrotic effects.
This is supported by a study showing a ↓ in serum carboxyl-terminal peptide of procollagen type I with torsemide.
t.ly/Vg6f
14/
Collectively, there is good support for the idea that torsemide does more than simply promote natriuresis/diuresis.
Whether these additional effects lead to observed differences in patient-centered outcomes isn't as clear.
Collectively, there is good support for the idea that torsemide does more than simply promote natriuresis/diuresis.
Whether these additional effects lead to observed differences in patient-centered outcomes isn't as clear.
15/15 SUMMARY
⚡️Available evidence favors torsemide over furosemide
⚡️Torsemide has better pharmacokinetics and a longer duration of action
⚡️Torsemide may be more than a loop diuretic!
⚡️Available evidence favors torsemide over furosemide
⚡️Torsemide has better pharmacokinetics and a longer duration of action
⚡️Torsemide may be more than a loop diuretic!
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