The Generalist: Loop Diuretics in Heart Failure

The Generalist: Loop Diuretics in Heart Failure

Andrew Buelt, DO, and Heidi James, MD

Prepare to have your mind blown! In this practice-changing segment, Andrew Buelt tells us that furosemide is not the only loop diuretic and that other options are probably better for our patients with heart failure.

• Furosemide has the lion’s share of the heart failure loop diuretic market.
• Few docs have heard of—or use—torsemide or bumetanide, even though evidence supports their use.
• Torsemide:
  • Licensed in 1993, now generic
  • Available in oral and IV forms
  • Advantages over furosemide:
    • Better oral bioavailability 
    • Longer duration of action = once-daily dosing
    • Metabolized by liver and kidneys; better in renal failure
    • Study proven
      • Decrease in heart failure readmissions
      • Reduced mortality
      • Improved New York Heart Association functional class status
      • The number needed to treat (NNT) at 10.5 months to prevent a heart failure hospitalization with torsemide is ~6.

• Bumetanide:
  • Licensed in 1972, now generic
  • Available in oral and IV forms
  • Advantages over furosemide:
    • Better oral bioavailability
    • Metabolized by liver and kidneys; better in renal failure
  • Compared to furosemide
    • Less dyspnea at rest and exertion

PEARL: Consider torsemide and bumetanide for your heart failure patients. 

REFERENCES:

A reappraisal of loop diuretic choice in heart failure patients
Buggey J, Mentz RJ, Pitt B, et al. Am Heart J. 2015;169(3):323-333. doi: 10.1016/j.ahj.2014.12.009. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4346710/ 

Open-label randomized trial of torsemide compared with furosemide therapy for patients with heart failure
Murray MD, Deer MM, Ferguson JA, et al. Am J Med. 2001;111(7):513-520. doi: 10.1016/s0002-9343(01)00903-2. https://pubmed.ncbi.nlm.nih.gov/11705426/ 

Torasemide in chronic heart failure: results of the TORIC study
Cosín J, Díez J; TORIC investigators. Eur J Heart Fail. 2002;4(4):507-513. doi:10.1016/s1388-9842(02)00122-8. [published correction appears in Eur J Heart Fail. 2002;4(5):667] https://pubmed.ncbi.nlm.nih.gov/12167392/

Torsemide versus furosemide and intermediate-term outcomes in patients with heart failure: an updated meta-analysis
Miles JA, Hanumanthu BK, Patel K, et al. J Cardiovasc Med (Hagerstown). 2019;20(6):379-388. doi: 10.2459/JCM.0000000000000794. https://pubmed.ncbi.nlm.nih.gov/30950982/

TRANSFORM-HF: ToRsemide compArisoN With furoSemide FORManagement of Heart Failure (TRANSFORM-HF). https://clinicaltrials.gov/ct2/show/NCT03296813.

Should Torsemide Be the Loop Diuretic of Choice in Systolic Heart Failure?
DiNicolantonio JJ. Future Cardiol. 2012;8(5):707-728. https://www.medscape.com/viewarticle/771976_8 

Healthcare costs of patients with heart failure treated with torasemide or furosemide
Stroupe KT, Forthofer MM, Brater DC, et al. Pharmacoeconomics. 2000;17(5):429-440. doi: 10.2165/00019053-200017050-00002. https://pubmed.ncbi.nlm.nih.gov/10977385/

Bioavailability, pharmacokinetics, and pharmacodynamics of torsemide and furosemide in patients with congestive heart failure
Vargo DL, Kramer WG, Black PK, et al. Clin Pharmacol Ther. 1995;57(6):601-609. doi: 10.1016/0009-9236(95)90222-8. https://pubmed.ncbi.nlm.nih.gov/7781259/

A comprehensive review of the loop diuretics: should furosemide be first line?
Wargo KA, Banta WM. Ann Pharmacother. 2009;43(11):1836-1847. doi: 10.1345/aph.1M177.

https://journals.sagepub.com/doi/10.1345/aph.1M177

Clinical pharmacology in diuretic use
Ellison DH. Clin J Am Soc Nephrol. 2019;14(8):1248-1257. doi: 10.2215/CJN.09630818. https://cjasn.asnjournals.org/content/14/8/1248

Diuretic therapy for patients with heart failure: JACC state-of-the-art review
Felker GM, Ellison DH, Mullens W, et al. J Am Coll Cardiol. 2020;75(10):1178-1195. doi: 10.1016/j.jacc.2019.12.059.

RELATED CONTENT:

EM:RAP 2016 February: A Fib Gets The Royal Treatment - Medical Myths - The Loop Diuretic

EMA 2011 September: Abstract 8: Diuretic Strategies In Patients With Acute Decompensated Heart Failure

EM:RAP 2017 September: Mildly Acidotic - Pharmacology Rounds – Furosemide in Renal Insufficiency

CorePendium: Heart Failure