Diuretics

Lilley Reading & Workbook, Chap 25

Drugs that accelerate the rate of urine formation

In the nephron, where sodium goes, water follows
20% to 25% of all sodium is reabsorbed into the bloodstream in the ascending loop of Henle 5% to 10% in the distal convoluted tubules 3% in collecting ducts If water is not absorbed, it is excreted as urine Result: removal of sodium and water

Carbonic anhydrase inhibitors Loop diuretics Osmotic diuretics Potassium-sparing diuretics Thiazide and thiazide-like diuretics

The enzyme carbonic anhydrase helps to make H+ ions available for exchange with sodium and water in the proximal tubules CAIs
block the action of carbonic anhydrase, thus preventing the exchange of H+ ions with sodium and water reduces H+ ion concentration in renal tubules

Result:
increased excretion of bicarbonate, sodium, water, & K+ Resorption of water is decreased and urine volume is increased

acetazolamide (Diamox) methazolamide dichlorphenamide

Adjunct drugs in the long-term management of open-angle glaucoma* Used with miotics to lower intraocular pressure before ocular surgery in certain cases Also useful in the treatment of: Edema* Epilepsy High-altitude sickness Acetazolamide (Diamox) is used in the management of edema secondary to HF when other diuretics are not effective* CAIs are less potent diuretics than loop diuretics or thiazides the metabolic acidosis they induce reduces their diuretic effect in 2-4 days

Metabolic acidosis Anorexia Hematuria Photosensitivity Melena

Hypokalemia Drowsiness Paresthesias Urticaria

Act directly on the ascending limb of the loop of Henle to inhibit chloride and sodium resorption Increase renal prostaglandins, resulting in the dilation of blood vessels and reduced peripheral vascular resistance bumetanide (Bumex) ethacrynic acid (Edecrin) furosemide (Lasix)

Potent diuresis and subsequent loss of fluid

Decreased fluid volume causes:
Reduced BP Reduced pulmonary vascular resistance Reduced systemic vascular resistance Reduced central venous pressure Reduced left ventricular end-diastolic pressure

Potassium and sodium depletion

Edema associated with HF or hepatic or renal disease Control of hypertension Increase renal excretion of calcium in patients with hypercalcemia

Certain cases of HF resulting from diastolic dysfunction

Body System
CNS

Adverse Effects
Dizziness, headache, tinnitus, blurred vision
Nausea, vomiting, diarrhea Agranulocytosis, neutropenia, thrombocytopenia

GI Hematologic

Metabolic

Hypokalemia, hyperglycemia, hyperuric

Work mostly in the proximal tubule Nonabsorbable, producing an osmotic effect

Pull water into renal tubules from the surrounding tissues

Inhibits tubular resorption of water and solutes

Increases glomerular filtration and renal plasma

Reduces excessive intraocular pressure

Used in the treatment of patients in the early, oliguric phase of ARF To promote the excretion of toxic substances Reduction of intracranial pressure Treatment of cerebral edema NOT indicated for peripheral edema

Convulsions
Thrombophlebitis Pulmonary congestion Also headaches, chest pains, tachycardia, blurred vision, chills, and fever

mannitol (Osmitrol)

Intravenous infusion only

May crystallize when exposed to low temperaturesuse of a filter is required

Interfere with sodium-potassium exchange in collecting ducts and convoluted tubules Competitively bind to aldosterone receptors
Block the resorption of sodium and water

Prevent potassium from being pumped into the tubule, thus preventing its secretion

Competitively block the aldosterone receptors and inhibit its action

Sodium and water are excreted

amiloride (Midamor) spironolactone (Aldactone) triamterene (Dyrenium)

Also known as aldosterone-inhibiting diuretics

spironolactone and triamterene

Hyperaldosteronism Hypertension Reversing the potassium loss caused by potassium-losing drugs Certain cases of heart failure Liver failure

Amiloride
Treatment of HF

Body System
CNS GI Other

Adverse Effects
Dizziness, headache Cramps, nausea, vomiting, diarrhea Urinary frequency, weakness

**hyperkalemia**

Spironolactone

Gynecomastia Amenorrhea Irregular menses Postmenopausal bleeding

Actions: Acts in the distal convoluted tubule

Inhibit tubular resorption of sodium, chloride, and potassium ions Result: water, sodium, and chloride are excreted

Potassium is also excreted to a lesser extent Dilate the arterioles by direct relaxation

Results:
Lowered peripheral vascular resistance Sodium, water, chloride and potassium are excreted

Thiazide diuretics
hydrochlorothiazide (Esidrix, HydroDIURIL) chlorothiazide (Diuril) trichlormethiazide (Metahydrin)

Thiazide-like diuretics
chlorthalidone (Hygroton) metolazone (Mykrox, Zaroxolyn)

Thiazides should not be used if creatinine clearance is less than 30 to 50 mL/min (normal is 125 mL/min) Metolazone (Zaroloxyn) remains effective to a creatinine clearance of 10 mL/min

Hypertension first line drug for HTN Edematous states Idiopathic hypercalciuria Diabetes insipidus

Heart failure due to diastolic dysfunction

Adjunct drugs in treatment of edema related to HF, hepatic cirrhosis, corticosteroid therapy

Body System
CNS

Adverse Effects
Dizziness, headache, blurred vision, paresthesias, decreased libido Anorexia, nausea, vomiting, diarrhea Impotence Urticaria, photosensitivity Hypokalemia, glycosuria, hyperglycemia, hyperuricemia

GI

GU Integumentary Metabolic

OTHER EFFECTS ALSO

Thorough patient history and physical examination

Assess baseline fluid volume status, intake and output, serum electrolyte values, weight, and vital signs especially postural BPs/orthostatic BPs
Assess for disorders that may contraindicate or necessitate cautious use of these drugs

Monitor serum K+ levels during therapy

K+ supplements are usually recommended to maintain K+ levels at approximately 4 mEq/L

Instruct patients to take in the morning as much as possible to avoid interference with sleep patterns
Teach patients to maintain proper nutritional and fluid volume status Teach patients to eat more potassium-rich foods when taking any but the potassium-sparing drugs Foods high in potassium include bananas, oranges, dates, raisins, plums, fresh vegetables, potatoes, meat, and fish, apricots, whole grain cereals, legumes

Patients taking diuretics along with a digitalis preparation digoxin (Lanoxin) should be taught to monitor for digitalis toxicity
Diabetic patients who are taking thiazide and/or loop diuretics should be told to monitor blood glucose and watch for elevated levels Change positions slowly, and to rise slowly after sitting or lying to prevent dizziness and possible fainting related to orthostatic hypotension

Encourage patients to keep a log of their daily weight A weight gain of 2 or more pounds a day or 5 or more pounds a week should be reported immediately Encourage patients to return for follow-up visits and labwork

Notify physician if you are ill with nausea, vomiting, and/or diarrhea because fluid loss may be dangerous

Excessive consumption of licorice can lead to an additive hypokalemia in patients taking thiazides Signs and symptoms of hypokalemia include muscle weakness, constipation, irregular pulse rate, and overall feeling of lethargy Notify the physician immediately if rapid heart rate or syncope occurs (reflects hypotension or fluid loss)

Diuretics are used for which of the following reasons? (Select all that apply.)
1. treat hypertension 2. treat edema with heart failure 3. increase urine fl ow 4. treat hyperuricemia (increased uric acid level)

Potassium-sparing diuretics are administered in combination with other types of diuretics to do which of the following? (Select all that apply.) 1. treat hypertension 2. treat heart failure 3. prevent hypokalemia 4. prevent hyperkalemia

The most potent class of diuretics currently available is:

1. thiazide-type. 2. potassium-sparing type. 3. loop-type. 4. carbonic anhydrase inhibitor.

Patients with diabetes mellitus receiving a diuretic should be observed for: 1. hypoglycemia. 2. hyperglycemia. 3. hyperkalemia. 4. normonatremia.