A Life-Threatening Case of Torsemide-Induced Toxic Epidermal Necrolysis Associated With the Treatment of Anasarca

A disproportionality analysis of adverse events associated with loop diuretics in the FDA Adverse Event Reporting System (FAERS)

BACKGROUND

Loop diuretics, including furosemide, torsemide, and bumetanide, are widely utilized in the management of volume overload-related conditions. Although previous studies have extensively documented risks such as electrolyte imbalances, ototoxicity, and nephrotoxicity, real-world evidence regarding novel or underrecognized adverse event (AE) signals remains limited and underexplored.

METHODS

Using data from the Food and Drug Administration Adverse Event Reporting System (FAERS) from the first quarter of 2004 to the third quarter of 2024, we conducted a disproportionality analysis integrating Reporting Odds Ratio (ROR), Proportional Reporting Ratio (PRR), Bayesian Confidence Propagation Neural Network (BCPNN), and Empirical Bayesian Geometric Mean (EBGM), combined with multivariate logistic regression. It is considered a significant signal when one of the four indicators meets the criteria. The temporal characteristics were elucidated via time-to-onset (TTO) analysis.

RESULTS

A total of 24,875 AE reports were analyzed, with furosemide accounting for 89.18%, torsemide for 8.33%, and bumetanide for 2.47%. Commonly reported risks included electrolyte imbalances, fluid balance disorders, and nephrotoxicity. Several novel safety signals were identified: furosemide was significantly associated with vitamin B1 deficiency (TTO = 71 days), Wernicke's encephalopathy (TTO = 2167 days), and gastrointestinal mucosal pigmentation (TTO = 549.1 days). Torsemide was associated with palisaded neutrophilic granulomatous dermatitis (TTO = 62.8 days), systemic infection (TTO = 548.3 days), pemphigoid (TTO = 470.6 days), bleeding events (involving the respiratory, gastrointestinal, and urinary tracts), and prolonged prothrombin time (TTO = 159.4 days). Bumetanide was linked to blood ketone body increased (TTO = 9.0 days), metabolic encephalopathy (TTO = 1786.0 days), and immune hypersensitivity reactions (Stevens-Johnson syndrome, pemphigoid, and lip swelling).

CONCLUSION

This study identified both common and drug-specific AEs associated with loop diuretics, particularly focusing on the metabolic and immune risks of long-term use. To enhance patient safety, clinicians are advised to develop personalized monitoring strategies based on individual patient characteristics. For furosemide, monitoring and supplementation of vitamin B1 and magnesium are recommended. For torsemide, attention should be given to coagulation function and delayed hypersensitivity reactions. For bumetanide, close monitoring of metabolic disorders and immune-related skin lesions is essential. These findings support individualized therapy and precise pharmacovigilance, ensuring safer and more effective use of loop diuretics.

Medication Associations With Severe Cutaneous Adverse Reactions: A Case/Non-Case Analysis Using the FDA Adverse Event Reporting System

BACKGROUND

Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), and acute generalized exanthematous pustulosis (AGEP) are potentially life-threatening severe cutaneous adverse reactions (SCARs). Although the classical causal agents of SCARs (antibiotics, anticonvulsants, nonsteroidal anti-inflammatory drugs, and allopurinol) are well characterized, there has been little update to this list to account for newly marketed medications.

OBJECTIVE

To provide an updated and stratified list of medications with significant reporting odds ratios (RORs) of SCARs.

METHODS

A case/non-case analysis using the United States FDA Adverse Event Reporting System was performed.

RESULTS

As expected, the prototypical medication classes made up the majority of reported cases of SJS, TEN, AGEP, and DRESS (77%, 64%, 75%, and 72%, respectively). In addition, several infrequently or previously undescribed classes/medications implicated in SCARs were identified to have significant ROR signals, including acetylcysteine, anticoagulants, diuretics, immunotherapies, proton pump inhibitors, antivirals, and antifungals. Among these reported for SJS were acetylcysteine (ROR: 64.38) and fluconazole (ROR: 17.13). For TEN, we identified furosemide (ROR: 26.32), spironolactone (ROR: 14.45), fluconazole (ROR: 30.21), amphotericin B (39.06), and acetylcysteine (ROR: 93.12). For AGEP, we identified acyclovir (ROR: 61.72), valacyclovir (ROR: 30.76), and enoxaparin (ROR: 27.37). For DRESS, we identified vemurafenib (ROR: 17.35), acyclovir (ROR: 30.63), abacavir (ROR: 26.62), raltegravir (ROR: 23.27), and valacyclovir (ROR: 21.77) to have strong reporting odds.

CONCLUSION

Our analysis provides an updated tool for physicians to reference when identifying suspected SCARs and a basis for future studies to investigate atypical medication causality.

Case Report: A successful case of toxic epidermal necrolysis treated with plasmapheresis therapy

Toxic epidermal necrosis (TEN) is rare and can be life-threatening for patients. Appropriate management of TEN patients could give optimal results and prevent complications. One treatment modality for TEN is plasmapheresis, which is rarely available in most cases with severe TEN. Here we reported a successful treatment of severe TEN with plasmapheresis. A 40-year-old woman under tuberculosis therapy complained of shortness of breath that began four days prior to hospital admission and worsened ever since. The patient's skin was peeling with red spots and rashes all over the body for a week. During the examination, the patient was compos mentis, and the SCORTEN score was 2 with 12.1% risk of mortality rate. Dermatological examination of the face, trunk and extremities found extensive erosions, loose bullae filled with clear fluid, brown crusts, and generalized distribution with more than 30% epidermolysis. The patient was diagnosed with toxic epidermal necrolysis caused by antituberculosis therapy. We treated the patient by discontinuing the suspected drugs and administering the corticosteroids, but no improvement was observed. The patient underwent two cycle plasmaphereses with 5% albumin, resulting in 1.2 liter of plasma exchange. Re-epithelialization was observed after three days, and the patient was discharged on day 8. This case-report highlights the important role of plasmapheresis in treating the TEN patients. However, a study with larger sample sizes is warranted to validate the efficacy of plasmapheresis in TEN.