HIGHLIGHTS OF PRESCRIBING INFORMATION ----------------------- WARNINGS AND PRECAUTIONS ----------------------­ These highlights do not include all the information needed to use • Hypotension and worsening renal function: monitor volume status and DEMADEX® safely and effectively. See full prescribing information for renal function periodically (5.1) DEMADEX • Electrolyte and metabolic abnormalities: monitor serum electrolytes and blood glucose periodically. (5.2) DEMADEX (torsemide) tablets, for oral use • Ototoxicity (5.3, 7.6) Initial U.S. Approval: 1993 ------------------------------ ADVERSE REACTIONS -----------------------------­ --------------------------- INDICATIONS AND USAGE ---------------------------­ The most common adverse reaction is excessive urination (6.7%). (6.1) DEMADEX is a loop diuretic indicated for: • the treatment of edema associated with heart failure, renal disease or To report SUSPECTED ADVERSE REACTIONS, contact Meda hepatic disease. (1.1) Pharmaceuticals Inc. at 1-800-526-3840 or FDA at 1-800-FDA-1088 • the treatment of hypertension, to lower blood pressure. Lowering blood or www.fda.gov/medwatch. pressure reduces the risk of fatal and nonfatal cardiovascular events, ------------------------------ DRUG INTERACTIONS------------------------------­ primarily strokes and myocardial infarctions. (1.2) • Non-steroidal anti-inflammatory drugs (NSAIDs): Reduced diuretic, ----------------------- DOSAGE AND ADMINISTRATION ----------------------­ natriuretic, and antihypertensive effects; risk of renal impairment. (7.1) Edema associated with: • CYP2C9: Concomitant use with CYP2C9 inhibitors can decrease • Heart failure: Initial dose is 10 or 20 mg once daily. Titrate by factors of torsemide clearance. Torsemide may affect the efficacy and safety of two; doses above 200 mg have not been studied. (2.1) sensitive CYP2C9 substrates or of substrates with a narrow therapeutic • Chronic Renal Failure: Initial dose is 20 mg once daily. Titrate by factors range, such as warfarin or phenytoin. (7.2) of two; doses above 200 mg have not been studied. (2.1) • Cholestyramine: Decreased exposure of DEMADEX.(7.3) • Hepatic Cirrhosis: Initial dose is 5 or 10 mg once daily. Titrate by factors • Organic anion drugs: may decrease diuretic activity of DEMADEX. (7.4) of two; doses above 40 mg have not been studied. (2.1) • Lithium: Risk of lithium toxicity (7.5) Hypertension: • Renin-angiotensin inhibitors: Increased risk of hypotension and renal • The recommended initial dose is 5 mg once daily. After 4-6 weeks, impairment. (7.7) increase to 10 mg once daily, if needed. If 10 mg is insufficient, consider • Radiocontrast agents: Increased risk of renal toxicity. (7.8) adding another agent. (2.2) • Corticosteroids and ACTH: Increased risk of hypokalemia. (7.9) --------------------- DOSAGE FORMS AND STRENGTHS ---------------------­ Tablets: 5 mg, 10 mg, 20 mg and 100 mg (3) See 17 for PATIENT COUNSELING INFORMATION ------------------------------ CONTRAINDICATIONS -----------------------------­ Revised: [02/2017] Hypersensitivity to DEMADEX or povidone, anuria, and hepatic coma. (4) FULL PRESCRIBING INFORMATION: CONTENTS* 7.7 Renin Angiotensin Inhibitors 7.8 Radiocontrast Agents 1 INDICATIONS AND USAGE 7.9 Corticosteroids and ACTH 1.1 Edema 8 USE IN SPECIFIC POPULATIONS 1.2 Hypertension 8.1 Pregnancy 2 DOSAGE AND ADMINISTRATION 8.2 Lactation 2.1 Treatment of Edema 8.4 Pediatric Use 2.2 Treatment of Hypertension 8.5 Geriatric Use 3 DOSAGE FORMS AND STRENGTHS 8.6 Use in Renal Impairment 4 CONTRAINDICATIONS 8.7 Use in Hepatic Impairment 5 WARNINGS AND PRECAUTIONS 10 OVERDOSE 5.1 Hypotension and Worsening Renal Function 11 DESCRIPTION 5.2 Electrolyte and Metabolic Abnormalities 12 CLINICAL PHARMACOLOGY 5.3 Ototoxicity 12.1 Mechanism of Action 6 ADVERSE REACTIONS 12.2 Pharmacodynamics 6.1 Clinical Trials Experience 12.3 Pharmacokinetics 6.2 Postmarketing Experience 13 NONCLINICAL TOXICOLOGY 7 DRUG INTERACTIONS 13.1 Carcinogenesis, Mutagenesis and Impairment of Fertility 7.1 Nonsteroidal Anti-inflammatory Drugs 16 HOW SUPPLIED/ STORAGE AND HANDLING 7.2 Cytochrome P450 2C9 Inhibitors and Inducers 17 PATIENT COUNSELING INFORMATION 7.3 Cholestyramine 7.4 Organic Anion Drugs *Sections or subsections omitted from the full prescribing information are not 7.5 Lithium listed. 7.6 Ototoxic Drugs Reference ID: 4051083 FULL PRESCRIBING INFORMATION 1 INDICATIONS AND USAGE 1.1 Edema DEMADEX is indicated for the treatment of edema associated with heart failure, renal disease or hepatic disease. 1.2 Hypertension DEMADEX is indicated for the treatment of hypertension, to lower blood pressure. Lowering blood pressure reduces the risk of fatal and nonfatal cardiovascular events, primarily strokes and myocardial infarctions. These benefits have been seen in controlled trials of antihypertensive drugs from a wide variety of pharmacologic classes including the class to which this drug principally belongs. There are no controlled trials demonstrating risk reduction with DEMADEX. Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake. Many patients will require more than one drug to achieve blood pressure goals. For specific advice on goals and management, see published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC). Numerous antihypertensive drugs, from a variety of pharmacologic classes and with different mechanisms of action, have been shown in randomized controlled trials to reduce cardiovascular morbidity and mortality, and it can be concluded that it is blood pressure reduction, and not some other pharmacologic property of the drugs, that is largely responsible for those benefits. The largest and most consistent cardiovascular outcome benefit has been a reduction in the risk of stroke, but reductions in myocardial infarction and cardiovascular mortality also have been seen regularly. Elevated systolic or diastolic pressure causes increased cardiovascular risk, and the absolute risk increase per mmHg is greater at higher blood pressures, so that even modest reductions of severe hypertension can provide substantial benefit. Relative risk reduction from blood pressure reduction is similar across populations with varying absolute risk, so the absolute benefit is greater in patients who are at higher risk independent of their hypertension (for example, patients with diabetes or hyperlipidemia), and such patients would be expected to benefit from more aggressive treatment to a lower blood pressure goal. The antihypertensive effects of DEMADEX are on the average greater in black patients than in nonblack patients [see Clinical Pharmacology (12.2)]. Some antihypertensive drugs have smaller blood pressure effects (as monotherapy) in black patients, and many antihypertensive drugs have additional approved indications and effects (e.g., on angina, heart failure, or diabetic kidney disease). These considerations may guide selection of therapy. DEMADEX can be used alone or in combination with other antihypertensive agents. 2 DOSAGE AND ADMINISTRATION 2.1 Treatment of Edema Edema associated with heart failure The recommended initial dose is 10 mg or 20 mg oral DEMADEX once daily. If the diuretic response is inadequate, titrate upward by approximately doubling until the desired diuretic response is obtained. Doses higher than 200 mg have not been adequately studied. Edema associated with chronic renal failure The recommended initial dose is 20 mg oral DEMADEX once daily. If the diuretic response is inadequate, Reference ID: 4051083 titrate upward by approximately doubling until the desired diuretic response is obtained. Doses higher than 200 mg have not been adequately studied. Edema associated with hepatic cirrhosis The recommended initial dose is 5 mg or 10 mg oral DEMADEX once daily, administered together with an aldosterone antagonist or a potassium-sparing diuretic. If the diuretic response is inadequate, titrate upward by approximately doubling until the desired diuretic response is obtained. Doses higher than 40 mg have not been adequately studied in this population. 2.2 Treatment of Hypertension The recommended initial dose is 5 mg once daily. If the 5 mg dose does not provide adequate reduction in blood pressure within 4 to 6 weeks, increase to 10 mg once daily. If the response to 10 mg is insufficient, add another antihypertensive agent to the treatment regimen. 3 DOSAGE FORMS AND STRENGTHS DEMADEX is available as white scored tablets in 5-, 10-, 20-, and 100-mg strengths. 4 CONTRAINDICATIONS DEMADEX is contraindicated in patients with known hypersensitivity to DEMADEX or to povidone. DEMADEX is contraindicated in patients who are anuric. DEMADEX is contraindicated in patients with hepatic coma. 5 WARNINGS AND PRECAUTIONS 5.1 Hypotension and Worsening Renal Function Excessive diuresis may cause potentially symptomatic dehydration, blood volume reduction and hypotension and worsening renal function, including acute renal failure particularly in salt-depleted patients or those taking renin-angiotensin aldosterone inhibitors. Worsening of renal function can also occur with concomitant use of nephrotoxic drugs (e.g., aminoglycosides, cisplatin, and NSAIDs). Monitor volume status and renal function periodically. 5.2 Electrolyte and Metabolic