POTASSIUM-SPARING DIURETICS

 Weaker than thiazides and loop diuretics, are used as mild diuretics or in combination with
another diuretic (e.g., hydrochlorothiazide, antihypertensive drugs).

 Continuous use of potassium-wasting diuretics requires a daily oral potassium supplement,

because the kidneys excrete potassium, sodium, and body water.

 The serum potassium should be periodically monitored when the patient continuously takes a
potassium-sparing diuretic. If the serum potassium level is greater than 5.3 mEq/L, the patient
should discontinue the potassium sparing diuretic and restrict foods high in potassium.

 Potassium-sparing diuretics act primarily in the collecting duct renal tubules and late distal
tubule to promote sodium and water excretion and potassium retention.

 The drugs interfere with the sodium-potassium pump controlled by the mineralocorticoid
hormone aldosterone (sodium retained and potassium excreted).

 Spironolactone (Aldactone), an aldosterone antagonist discovered in 1958, was the first

potassium-sparing diuretic.

 Aldosterone is a mineralocorticoid hormone that promotes sodium retention and potassium

excretion. Spironolactone blocks the action of aldosterone and inhibits the sodiumpotassium
pump (i.e., potassium is retained and sodium is excreted).

 Spironolactone (Aldactone) has been prescribed by cardiologists for patients with cardiac
disorders because of its potassium-retaining effect. As a result of the action of spironolactone,
the heart rate is more regular, and the possibility of myocardial fibrosis is decreased. The effects
of spironolactone may take 48 hours.

 Triamterene is useful in the treatment of edema caused by HF or cirrhosis of the liver. Low doses
of spironolactone (Aldactone) and eplerenone are effective for chronic HF. Spironolactone,
amiloride,
 triamterene, and eplerenone should not be taken with ACE inhibitors and angiotensin II receptor
blockers (ARBs) because they can also increase serum potassium levels.

 Usually combined with a potassium-wasting diuretic, primarily hydrochlorothiazide or a loop

diuretic. The combination of potassium sparing and potassium-wasting diuretics intensifies the
diuretic effect and prevents potassium loss.

 The common combination diuretics contain spironolactone and hydrochlorothiazide

(Aldactazide), amiloride and hydrochlorothiazide (HCTZ), and triamterene and
hydrochlorothiazide (Dyazide, Maxzide).
Side Effects and Adverse Reactions

 Hyperkalemia

 Monitoring serum potassium levels is essential to safe drug therapy.

 GI disturbances (anorexia, nausea, vomiting, diarrhea, and numbness and tingling of the hands
and feet) can occur.

ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS

ACE inhibitors inhibit ACE, which in turn inhibits the formation of angiotensin II (vasoconstrictor) and
blocks the release of aldosterone. Aldosterone promotes sodium retention and potassium excretion.
When aldosterone is blocked, sodium is excreted along with water, and potassium is retained. ACE
inhibitors cause little change in cardiac output or heart rate,
and they lower peripheral resistance. (Figure 44-1 illustrates
the RAAS.) These drugs can be used in patients who have
elevated serum renin levels.
The ACE inhibitors are used primarily to treat hypertension;
some of these agents are also effective in treating
heart failure. The ACE inhibitors are benazepril (Lotensin),
captopril (Capoten), enalapril maleate (Vasotec), fosinopril
(Monopril), lisinopril (Prinivil, Zestril), moexipril (Univasc),
perindopril (Aceon), quinapril (Accupril), ramipril (Altace),
and trandolapril (Mavik), which are all presented in
Table 44-3. These drugs can be used for first-line antihypertensive
therapy, but thiazide diuretics are recommended
by JNC 7.
African Americans and older adults do not respond to
ACE inhibitors with the desired reduction in blood pressure,
but when taken with a diuretic, blood pressure usually will
be lowered. ACE inhibitors should not be given during pregnancy,
because they reduce placental blood flow. For patients
with renal insufficiency, reduction of the drug dose (except
for fosinopril), is necessary.