Drugs List

Therapeutic Indications

Uses

Oedema due to cardiac failure
Oedema of hepatic/pulmonary or renal origin
Treatment of essential hypertension

Contraindications

Children under 18 years
Anuria
Breastfeeding
Cardiac arrhythmias
Galactosaemia
Hepatic coma
Hypotension
Long QT syndrome
Pre-coma associated with hepatic cirrhosis
Pregnancy
Renal damage secondary to nephrotoxic agents
Renal impairment secondary to hepatotoxic agents
Severe hypokalaemia
Severe hyponatraemia
Torsade de pointes

Precautions and Warnings

Elderly
Family history of long QT syndrome
Benign prostatic hyperplasia
Diabetes mellitus
Electrolyte imbalance
Glucose-galactose malabsorption syndrome
Gout
Hepatic impairment
History of torsade de pointes
Hyperuricaemia
Hypovolaemia
Lactose intolerance
Porphyria
Urinary obstruction

Correct hypotension before initiating treatment
Advise ability to drive/operate machinery may be affected by side effects
Correct existing water and electrolyte disturbances before administration
Not all available strengths are licensed for all indications
Contains lactose
Monitor serum electrolytes before and during treatment
Consider monitoring ECG in patients at risk of QT prolongation
Monitor antidiabetic drug treatment
Monitor blood / urinary glucose in patients suspected of latent diabetes
Monitor blood glucose
Monitor carbohydrate metabolism in diabetes mellitus
Monitor patients at risk of gout
Monitor renal function
Monitor serum creatinine
Monitor serum lipids
Monitor uric acid levels
Excess consumption of liquorice may increase the risk of hypokalaemia
Advise patient not to take NSAIDs unless advised by clinician

Use with caution in patients with urinary outflow obstruction such as in prostatic enlargement as torasemide may precipitate urinary retention in these patients.

Pregnancy and Lactation

Pregnancy

Torasemide is contraindicated in pregnancy.

Diuretics are no longer part of the standard therapy for hypertension and oedema during pregnancy, they should only be used for particular indications. There are no data available on the effect of torasemide on the human embryo and foetus. Whilst studies in rats have shown no teratogenic effect, malformed foetuses have been observed after high doses in pregnant rabbits.

Schaefer (2007) concludes that use of torasemide is not an indication for termination of pregnancy.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Torasemide is contraindicated during breastfeeding.

No studies have been conducted on excretion in breast milk. Its extraordinary high protein binding is likely to limit its transfer into human milk. As with many diuretics, reduction of plasma volume and hypotension may adversely reduce milk production. An alternative agent may be preferred especially whilst nursing a newborn or premature infant. Schaefer (2007) states that single doses of torasemide do not require limitation of breastfeeding, but therapy should be changed.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Aggravation of metabolic alkalosis
Allergic reaction
Anaemia
Angina
Asthenia
Bladder outflow obstruction
Cerebral ischaemia
Circulatory disturbances
Confusion
Decreased appetite
Disturbance of fluid balance
Dizziness
Dry mouth
Electrolyte disturbances
Exanthema
Fatigue
Gastro-intestinal symptoms
Headache
Hearing loss
Hypokalaemia
Hyponatraemia
Hypotension
Increase in serum glucose
Increased uric acid level
Increases in hepatic enzymes
Leukopenia
Muscular cramps
Myocardial infarction
Myocardial ischaemia
Pancreatitis
Paraesthesia
Photosensitivity
Pruritus
Rash
Rise in blood lipids
Serum creatinine increased
Serum urea increased
Stevens-Johnson syndrome
Syncope
Thrombocytopenia
Thromboembolic complications
Tinnitus
Toxic epidermal necrolysis
Urinary retention
Visual disturbances

Presentation

Oral formulations of torasemide.

Drugs List

Therapeutic Indications

Uses

Oedema due to cardiac failure
Oedema of hepatic/pulmonary or renal origin
Treatment of essential hypertension

Dosage

Adults

Contraindications

Children under 18 years
Anuria
Breastfeeding
Cardiac arrhythmias
Galactosaemia
Hepatic coma
Hypotension
Long QT syndrome
Pre-coma associated with hepatic cirrhosis
Pregnancy
Renal damage secondary to nephrotoxic agents
Renal impairment secondary to hepatotoxic agents
Severe hypokalaemia
Severe hyponatraemia
Torsade de pointes

Precautions and Warnings

Elderly
Family history of long QT syndrome
Benign prostatic hyperplasia
Diabetes mellitus
Electrolyte imbalance
Glucose-galactose malabsorption syndrome
Gout
Hepatic impairment
History of torsade de pointes
Hyperuricaemia
Hypovolaemia
Lactose intolerance
Porphyria
Urinary obstruction

Correct hypotension before initiating treatment
Advise ability to drive/operate machinery may be affected by side effects
Correct existing water and electrolyte disturbances before administration
Not all available strengths are licensed for all indications
Contains lactose
Monitor serum electrolytes before and during treatment
Consider monitoring ECG in patients at risk of QT prolongation
Monitor antidiabetic drug treatment
Monitor blood / urinary glucose in patients suspected of latent diabetes
Monitor blood glucose
Monitor carbohydrate metabolism in diabetes mellitus
Monitor patients at risk of gout
Monitor renal function
Monitor serum creatinine
Monitor serum lipids
Monitor uric acid levels
Excess consumption of liquorice may increase the risk of hypokalaemia
Advise patient not to take NSAIDs unless advised by clinician

Use with caution in patients with urinary outflow obstruction such as in prostatic enlargement as torasemide may precipitate urinary retention in these patients.

Pregnancy and Lactation

Pregnancy

Torasemide is contraindicated in pregnancy.

Diuretics are no longer part of the standard therapy for hypertension and oedema during pregnancy, they should only be used for particular indications. There are no data available on the effect of torasemide on the human embryo and foetus. Whilst studies in rats have shown no teratogenic effect, malformed foetuses have been observed after high doses in pregnant rabbits.

Schaefer (2007) concludes that use of torasemide is not an indication for termination of pregnancy.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Torasemide is contraindicated during breastfeeding.

No studies have been conducted on excretion in breast milk. Its extraordinary high protein binding is likely to limit its transfer into human milk. As with many diuretics, reduction of plasma volume and hypotension may adversely reduce milk production. An alternative agent may be preferred especially whilst nursing a newborn or premature infant. Schaefer (2007) states that single doses of torasemide do not require limitation of breastfeeding, but therapy should be changed.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Aggravation of metabolic alkalosis
Allergic reaction
Anaemia
Angina
Asthenia
Bladder outflow obstruction
Cerebral ischaemia
Circulatory disturbances
Confusion
Decreased appetite
Disturbance of fluid balance
Dizziness
Dry mouth
Electrolyte disturbances
Exanthema
Fatigue
Gastro-intestinal symptoms
Headache
Hearing loss
Hypokalaemia
Hyponatraemia
Hypotension
Increase in serum glucose
Increased uric acid level
Increases in hepatic enzymes
Leukopenia
Muscular cramps
Myocardial infarction
Myocardial ischaemia
Pancreatitis
Paraesthesia
Photosensitivity
Pruritus
Rash
Rise in blood lipids
Serum creatinine increased
Serum urea increased
Stevens-Johnson syndrome
Syncope
Thrombocytopenia
Thromboembolic complications
Tinnitus
Toxic epidermal necrolysis
Urinary retention
Visual disturbances

Overdosage

It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.

The following number will direct the caller to the relevant local centre (0844) 892 0111

Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Further Information

Last Full Review Date: December 2017.

Reference Sources

Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 10th edition (2015) ed. Briggs, G., Freeman, R. Wolters Kluwer Health, Philadelphia.

Drugs During Pregnancy and Lactation: Treatment Options and Risk Assessment, 3rd edition (2015) ed. Schaefer, C., Peters, P. and Miller, R. Elsevier, London.

Medications and Mothers' Milk, 14th Edition (2010) Hale, T. Hale Publishing, Amarillo, Texas.

Summary of Product Characteristics: Torem tablets 2.5mg. Meda Pharmaceuticals Ltd. Revised July 2016.
Summary of Product Characteristics: Torem tablets 5mg. Meda Pharmaceuticals Ltd. Revised July 2016.
Summary of Product Characteristics: Torem tablets 10mg. Meda Pharmaceuticals Ltd. Revised July 2016.

The Norwegian Porphyria Centre (NAPOS).
Available at: https://www.drugs-porphyria.org
Last revised: 16 April 2010.
Last accessed: 04 December 2017.

NICE Evidence Services Available at: www.nice.org.uk Last accessed: 04 December 2017.

US National Library of Medicine. Toxicology Data Network. Drugs and Lactation Database (LactMed).
Available at: https://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
Torasemide. Last revised: 10 March 2015.
Last accessed: 04 December 2017.