Torsemide over Furosemide as a first-line loop diuretic for HF


Dr. Anthony C. Brief

When starting a new diuretic loop for a patient with heart attack, consider firmly torsemide finished furosemide, Anthony C. Brief, MD, advised at SHM Converge, the annual conference of the Society of Hospital Medicine.

“Whether or not you take a patient who is already on furosemide and make the switch to torsemide is a little harder to defend, even though this has happened in clinical trials,” said Breu, an assistant professor of medicine at Harvard Medical. School, Boston, who spoke on May 5 at the Converge session “Things we do for no reason.” He co-presented the session with Leonard Feldman, MD, SFHM, director of the Osler Medical Residency Urban Health Track and associate professor of Johns Hopkins Medicine, Baltimore.

“If you plan to do this, it would make sense to do it in concert with the outpatient primary care physician and the outpatient cardiologist,” Breu said. “But in my review of the literature, it’s worth having these discussions, especially for a patient who has multiple readmissions for heart failure. It may be a time to pause and ask, ‘Could torsemide be helpful?’ here? “”

In Breu’s opinion, there are at least three reasons why torsemide should be considered a first-line treatment for heart failure. On the one hand, the current evidence says so. In a publication of the trial in 2001, researchers randomized 234 patients with heart failure to receive torsemide or furosemide for 1 year. The percentage of patients who had one or more hospital readmissions was lower among those who received torsemide, compared with those who received furosemide in the torsemide group for heart failure (17% vs. 32%, respectively; Pg <0.01) and for other cardiovascular causes (44% vs. 59%; Pg = .03). In addition, the number of total admissions was numerically lower for patients in the torsemide group, compared with the furosemide group for heart failure (23 vs. 61; Pg <0.01) and for cardiovascular causes (78 vs. 130; Pg = 0.02).

In a separate study, the researchers conducted an open-label trial of 237 New York Heart Association (NYHA) class II-IV heart failure patients who were randomized to torsemide or furosemide. They found that a significantly higher percentage of patients in the torsemide group improved in one or more classes of heart failure in the NYHA, compared with those in the furosemide group (40%; Pg = 0.001 vs. 31%; Pg = .3). In addition, patients treated with furosemide had more restrictions on daily life at 9 months, compared with those treated with torsemide (Pg <.001).

An independent, open brand, non-random postmarketing surveillance trial benefits of torsemide over furosemide or other agents used in patients with NYHA class III and IV heart failure were also found. Patients treated with torsemide had lower overall mortality, compared with those treated with furosemide or other agents (2.2% vs. 4.5%, respectively; Pg <0.05), as well as lower cardiac mortality (1.4% vs. 3.5%; Pg <.05). They were also more likely to improve in one or more classes of heart failure (46% vs. 37%; Pg <0.01) and less likely to have potassium levels less than 3.5 mEq / L or greater than 5.0 mEq / L (13% vs. 18%; Pg = .01).

According to Brief, meta-analyzes of this topic consistently show that the NYHA class improved better with torsemide than with furosemide. “Some meta-analyzes find a mortality benefit, while others find a readmission benefit,” he said. “None of them show a benefit of furosemide over torsemide.”

A second reason for using torsemide as a first-line treatment for heart failure is that it has superior pharmacokinetics / dynamics, compared to furosemide. “We’ve all heard that furosemide has a variable bioavailability,” said Brief, who was also the deputy editor of the “Things We Do For No Reason” article series in the Journal of Hospital Medicine. “Torsemide i bumetanide they are absorbed much more reliably, in part because they are not affected by food, while furosemide does. This could be potentially problematic for patients taking their diuretic with meals. The fact that torsemide has less renal clearance is an advantage, as patients with heart failure have changing kidney function. “In addition, the half-life of torsemide is 3-4 hours and the duration of action is 12 hours,” which are both longer than those of furosemide or bumetanide, ”he added.

He also noted that torsemide has been shown to block aldosterone receptor in vitro and in rat models, an effect that has not been observed with other loop diuretics. A randomized trial of patients with chronic heart failure found that renin and aldosterone levels increased more with torsemide, compared with furosemide, supporting the hypothesis of aldosterone receptor blockade.

A third major reason for using torsemide as a preferred method for heart failure has to do with its supposed antifibrotic effects, “so it could be more than a diuretic,” Brief said. “In heart failure, myocardial fibrosis occurs due to increased collagen synthesis and rotation. Aldosterone has been shown to play a role in this myocardial fibrosis. Spironolactone it has been shown to mitigate this to some extent. If torsemide acts a bit like spironolactone, maybe that could explain some of the long-term effects we see in these studies. “

A study support this notion found that torsemide, but not furosemide, reduced serum carboxyl-terminal peptide levels of type I procollagen, which is associated with excessive myocardial deposition of type I collagen fibers in heart disease. .

In the future, a study known as TRANSFORM-HF, which currently recruits about 6,000 patients, should shed more light on the issue. The main goal is to compare the treatment strategy of torsemide with furosemide in clinical outcomes for 12 months in hospitalized heart failure patients. The estimated completion is in mid-2022.

Brief and Feldman reported that they had no relevant financial information.

This article originally appeared in The Hospitalist, an official publication of the Society of Hospital Medicine.

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