An evaluation of torsemide in patients with heart failure and renal disease

ABSTRACT

Introduction

Torsemide is a loop diuretic that inhibits the Na+/K+/2Cl− cotransporter type 2 in the thick ascending loop of Henle, leading to increased excretion of urinary sodium and chloride and associated diuresis. While furosemide remains the dominant diuretic utilized in current practice, increasing evidence supports potential advantages of torsemide in heart failure (HF) and/or renal disease.

Areas covered

This narrative review covers the evidence for use of torsemide in HF and renal disease. Comparative effectiveness with regards to clinical outcomes is reviewed, as well as the ongoing multicenter trial, TRANSFORM-HF, comparing the effect of torsemide versus furosemide among patients with HF.

Expert opinion

Compared with furosemide, torsemide has favorable pharmacodynamics/pharmacokinetics including higher bioavailability, longer duration of effect, minor renal excretion, decreased kaliuresis, and enhanced natriuresis/diuresis. These properties may be further supported by differential effects on RAAS regulation and fibrosis modulation as compared with other diuretics. The limited current body of evidence indicates that torsemide may be superior to furosemide with respect to improving HF functional status and reducing HF hospitalization, and there are mixed data regarding effect on reducing overall cardiovascular hospitalizations/mortality. Further, randomized data are necessary to definitively determine if torsemide can reduce risk of mortality and hospitalization among patients with HF.

KEYWORDS:

• Torsemide
• diuretics
• heart failure
• renal disease
• drug profile
• comparative analysis

ARTICLE HIGHLIGHTS

• Torsemide is a loop diuretic prescribed for a minority of patients with heart failure and renal disease, despite growing evidence for its potential advantages.

• Torsemide demonstrates superior pharmacodynamics and pharmacokinetics compared with furosemide.

• There is some evidence that torsemide modulates the renin-angiotensin-aldosterone system and cardiac fibrosis processes.

• The current body of evidence indicates that torsemide may be superior to furosemide with respect to improving New York Heart Association functional class and reducing HF hospitalization, although data are limited.

• Further, randomized data are necessary to definitively determine if torsemide can conclusively reduce risk of mortality and hospitalization among patients with HF.

Declaration of Interest

A Peters is supported by the National Heart Lung and Blood Institute (T32HL069749). RJ Mentz has received research support and honoraria from Abbott, American Regent, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim/Eli Lilly, Boston Scientific, Cytokinetics, Fast BioMedical, Gilead, Innolife, Medtronic, Merck, Novartis, Relypsa, Respicardia, Roche, Sanofi, Vifor, Windtree Therapeutics, and Zoll. T DeWald has received research support from Novartis. S Greene has received research support from the Duke University Department of Medicine Chair’s Research Award, the American Heart Association, Amgen, AstraZeneca, Bristol Myers Squibb, Cytokinetics, Merck, Novartis, and Pfizer; has served on advisory boards for Amgen, AstraZeneca, Birstoly Myers Squibb, and Cytokinetics; and serves as a consultant for Amgen, Bayer, Bristol Myers Squibb, Merck, and Vifor.

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was supported in part by the NIH National Heart Lung and Blood Institute (T32HL069749).