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A Comprehensive Review of the Loop Diuretics: Should Furosemide Be First Line
Annals of Pharmacotherapy, 10/28/09

Wargo KA et al. – Growing evidence demonstrates more favorable pharmacokinetic profiles of torsemide and bumetanide compared with furosemide. Furthermore, torsemide may be more efficacious and safer than furosemide in patients with HF. A trial comparing all 3 drugs would be required to confirm torsemide as the primary loop diuretic in patients with HF, but based upon limited current evidence, the authors recommend torsemide over furosemide. Currently, little evidence exists to support either torsemide or bumetanide as first–line treatment over furosemide in patients with other edematous disease states.

Exclusive Author Commentary
Kurt A Wargo, 10/28/09

Through our review of the literature published on the utility of loop diuretics, we were able to determine that furosemide may not be the most ideal agent for the treatment of edema in patients with heart failure. This is contrary to what we commonly see in practice, but because of its more predictable pharmacokinetic profile, inhibition of the renin-angiotensin-aldosterone system, and prevention of fibrotic changes to the cardiac tissue, torsemide appears to have a clear advantage. Unfortunately, in other edematous states such as cirrhosis, pulmonary hypertension, and kidney disease, there was no clear advantage of torsemide over furosemide. Finally, little evidence exists that suggest bumetanide is better than furosemide for the treatment of these conditions. When selecting medications for our patients, cost should always be considered, to ensure they will better adhere to the regimen (or at least have the ability to purchase the medication). All loop diuretics are available in a generic formulation; however, torsemide is the most expensive of the three (costing approximately $20/month). Certainly furosemide and bumetanide are less expensive; however, pharmacoeconomic studies of patients with heart failure have demonstrated that torsemide significantly lowers overall healthcare costs. Therefore, for patients with heart failure, we recommend the use of torsemide over furosemide and bumetanide. Not enough evidence exists to make this recommendation for other edematous disease states.

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