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DIURETICS
Warde
Heheman
Diuretics
Classification of Diuretics
High ceiling (Loop) diureticsFurosemide (Lasix)
Thiazide diuretics
hydroclorothiazide (HCTZ)
Osmotic diuretics mannitol
(Osmitrol)
Potassium-sparing diuretics:
Aldosterone antagonists
spironolactone (Aldactone)
Nonaldosterone antagonists-
Thiazide Diuretics
PD: Increase renal excretion of sodium,
chloride, potassium, & water
Elevates plasma levels of uric acid &
glucose
Greatest difference between thiazides &
loop diuretics: maximum diuresis of
thiazides is considerably lower than in
loop diuretics
Thiazides are not effective when urine
flow is scant (anuria, severe renal
failure)
Thiazides: Hydrochlorothiazide
Hydrochlorothiazide (HydroDIURIL,
HCTZ) most widely used thiazide diuretic
Promotes urine production by blocking
reabsorption of sodium & chloride in the
early segment of the distal convoluted
tubule
Since only 10% of filtered sodium &
chloride is normally absorbed where
thiazides act, maximum urine flow is lower
than with Loop Diuretics
Cannot be used to promote fluid loss in pts
with severe renal impairment
Thiazides: Hydrochlorothiazide
Therapeutic Uses:
Essential Hypertension- Primary use is for
HTN, and is often FIRST DRUG OF
CHOICE.
Edema- Mild to moderate, heart failure
Diabetes Insipidus- Causes fluid retention
instead (unsure why)
Postmenopausal Osteoporosis
Protection,Promotes tubular reabsorption
of calcium
Thiazides:
Hydrochlorothiazide
Adverse Effects:
Hyponatremia, Hypochloremia &
Dehydration- Milder than loop diuretics
Hypokalemia- Eat potassium rich foods,
*careful if taking digoxin.
Pregnancy and Lactation: Direct and
Indirect effects on developing fetus, and
impair fetal blood flow
Should not be used routinely during
pregnancy, caution
Thiazides: Hydrochlorothiazide
Adverse Reaction:
Hyperglycemia- Can elevate glucose
in diabetic pts
Hyperuricemia- Retention of uric acid,
can cause gout.
Lipid and Magnesium- Increase LDL,
total cholesterol and triglycerides. Can
cause magnesium deficiency.
Thiazides:
Hydrochlorothiazide
Drug Interactions:
Same as loop diuretics, Slightly different
chemical structure, indications for use, PKs
Other Thiazide-Type diuretics:
True Thiazides:
Chlorothiazide (Diuril)
Methyclothiazide (Enduron)
Related to Thiazides:
Chlorthalidone (Hygroton) not for children, longer
half-life Indapamide (Lozol) specific for edema in
CHF, not for children, highly metab. in liver, caution
liver impaired
Metolazone (Zaroxolyn) not for children
Potassium-Sparing Diuretics
Produce increased urine production, but
limited, so not often used for diuresis
Produce substantial decrease in potassium
excretion, so these drugs are often
used to counteract potassium loss
caused by thiazide & loop diuretics.
Two subcategories:
Aldosterone Antagonists- spironolactone
(Aldactone)
Non-aldosterone antagonists- triamterene
(Dyrenium) and amiloride (Midamor)
Potassium-Sparing Diuretics:
Spironolactone
PD: Blocks the actions of aldosterone in
distal tubule, (blocks all aldosterone
receptors: glucocorticoid, mineral corticoid,
androgen, & progesterone)
Aldosterone promotes sodium uptake in
exchange for potassium secretion
PD: Spironolactone causes retention of
potassium and increased excretion of sodium
Effects of spironolactone are delayed (typically
takes 48 hrs) because it blocks the action of new
proteins but does not stop existing transport
proteins
Potassium-Sparing Diuretics:
Spironolactone (Aldactone)
Therapeutic Uses:
HTN & Edema- Most commonly used in
combination with a loop or thiazide diuretic
to counteract the potassium-wasting effects
of the more powerful diuretics
Heart Failure (CHF) Proven to reduce
mortality and hospital admissions
Other Uses- Primary hyper-aldosteronism,
Off label: premenstrual syndrome, polycystic
ovary syndrome, acne * assess what drug is
used for
Potassium-Sparing Diuretics:
Spironolactone
Adverse Effects:
Hyperkalemia- Most likely when
spironolactone is used alone, stop use if
hyperkalemia develops
Endocrine effects- Similar to other
steroid hormones (progesterone,
estradiol, testosterone). Can cause
gynecomastia, menstrual irregularities,
impotence, hirsutism & deepening of the
voice.
Potassium-Sparing Diuretics:
Spironolactone
Drug Interactions
Thiazide & Loop diuretics- given to
counteract the potassium-wasting effects.
Agents that raise potassium levels
should never be given with
potassium supplements, salt
substitutes or another potassiumsparing diuretic
If given with ACE Inhibitors, ARBs, or direct
renin inhibitors can elevate potassium levels
Potassium-Sparing Diuretics:
Triamterene (Dyrenium)
Therapeutic Uses:
Used alone or in combination with other
diuretics to treat HTN & edema
If Used alone produces mild diuresis
Used in combination, it augments
diuresis &helps counteract the
potassium wasting effects of the more
powerful diuretic
Potassium-Sparing Diuretics:
Triamterene (Dyrenium)
Adverse Effects:
Hyperkalemia- excessive accumulation is
the most significant adverse effect, likely
when triamterene is used alone. Should
never be used with another potassium
sparing diuretic or potassium
supplements or salt substitutes. Use
caution if giving with ACE Inhibitors, ARBs, or
direct renin inhibitor (increase the effect of
triamterene)
Other adverse effects- nausea, vomiting,
leg cramps, and dizziness.
Potassium-Sparing Diuretics:
Amiloride (Midamor)
Think Triamterene
Used primarily to counteract
potassium-wasting from other diuretics
Adverse Effect is hyperkalemia (watch
out with ACE Inhibitors, ARBs, direct
renin inhibitors)
DIURETIC
D- Diet, increase K (except potassiumsparing)
I- Intake, Output, and Daily Wt.
U- Undesirable effects; fluid and
electrolyte imbalance.
R- Review HR, BP, and electrolytes
E- Elderly-caution
T- Take with or after meals and in AM
I- Increased risk of orthostatic
hypotension
C- Cancel alcohol