Demadex


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torsemide (torasemide (UK))

Demadex, Torem (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) ,

Demadex

(trade name)

Classification

Therapeutic: antihypertensives
Pharmacologic: loop diuretics
Pregnancy Category: B

Indications

Edema due to:
  • HF,
  • Hepatic or renal disease.
Hypertension.

Action

Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule.
Increases renal excretion of water, sodium, chloride, magnesium, hydrogen, and calcium.
Effectiveness persists in impaired renal function.

Therapeutic effects

Diuresis and subsequent mobilization of excess fluid (edema, pleural effusions).
Decreased BP.

Pharmacokinetics

Absorption: 80% absorbed after oral administration.
Distribution: Widely distributed.
Protein Binding: ≥99%.
Metabolism and Excretion: 80% metabolized by liver, 20% excreted in urine.
Half-life: 3.5 hr.

Time/action profile (diuretic effect)

ROUTEONSETPEAKDURATION
POwithin 60 min60–120 min6–8 hr
IVwithin 10 minwithin 60 min6–8 hr

Contraindications/Precautions

Contraindicated in: Hypersensitivity;Cross-sensitivity with thiazides and sulfonamides may occur;Hepatic coma or anuria.
Use Cautiously in: Severe liver disease (may precipitate hepatic coma; concurrent use with potassium-sparing diuretics may be necessary);Electrolyte depletion;Diabetes mellitus;Increasing azotemia; Obstetric / Lactation / Pediatric: Safety not established; Geriatric: May have ↑ risk of side effects, especially hypotension and electrolyte imbalance, at usual doses.

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

HF
Oral Intravenous (Adults) 10–20 mg once daily; dose may be doubled until desired effect is obtained (maximum daily dose = 200 mg).
Chronic Renal Failure
Oral Intravenous (Adults) 20 mg once daily; dose may be doubled until desired effect is obtained (maximum daily dose = 200 mg).
Hepatic Cirrhosis
Oral Intravenous (Adults) 5–10 mg once daily (with aldosterone antagonist or potassium-sparing diuretic); dose may be doubled until desired effect is obtained (maximum daily dose = 40 mg).
Hypertension
Oral Intravenous (Adults) 2.5–5 mg once daily, may be ↑ to 10 mg once daily after 4–6 wk (if still not effective, add another agent).

Availability (generic available)

Tablets: 5 mg, 10 mg, 20 mg, 100 mg Cost: Generic — 5 mg $63.42 / 100, 10 mg $70.27 / 100, 20 mg $82.08 / 100, 100 mg $304.00 / 100
Injection: 10 mg/mL

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.

Demadex®

Torsemide Nephrology A loop diuretic as effective as furosemide, with longer duration of action. See Diuretic, Loop diuretic.
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