Diuretics

Alison J. Montpetit, RN, PhD

NURS 366 Spring 2015
 I. Overview
A. Kidney function
1. Maintain ECF volume and composition
2. Maintain acid - base balance
3. Excrete waste products and toxic substances
4. Nice review in Lehne r/t filtration, reabsorption,
secretion
B. Diuretic uses
1.Treatment of HTN
2.Mobilization of fluid
3.Prevent renal failure
C. Diuretic action
1. Most have same action
2. When solute reabsorption is blocked, tubular
osmotic pressure is increased and water is
therefore passively excreted also.
3. The amount of diuresis that occurs is directly
related to amount of Na and CL blockade.
4. The earlier the site of action in the nephron, the
greater the amount of Na and CL blockade.
 Osmotic diuretics Thiazide diuretics
Increases osmotic pressure so Similar to loops
H2O not filtered

Rule of thumb…the earlier in the K sparing

site of the nephron the greater Blocks
Loop diuretics aldosterone,
the diuretic effect Blocks NaCl
excretion of Na,
**dependent on renal function, etc. reabsorption
retention of K
 II. Types of Diuretics
A. High ceiling (Loop) Diuretics
1. Action
a) Most effective diuretics
b) Blocks significant amounts of NaCL reabsorption
2. Pharmacology
a) Acts quickly (in 60 minutes for po, 5 minutes with
IV)
b) Lasts 2 (IV) to 5 hrs (po)
3. Uses
a) For conditions requiring significant fluid loss
b) Acute pulm edema with CHF
c) Edema of liver disease
d) Effective in renal disease since it can cause diuresis even
with low GFR and RBF
e) Used after other diuretics have failed
f) More IS better
4. ADRs
a) Dehydration
b) Hypotension
c) Electrolyte imbalances; ↓Na, ↓K, ↓Cl
d) Ototoxicity
e) Hyperuricemia - common side effect but may be
asymptomatic – can lead to gout, kidney stones
5. Drug Interactions
a) Digoxin
b) Lithium - with low Na levels lithium level will
increase
c) Ototoxic drugs
d) Potassium sparing diuretics
e) Antihypertensives
f) NSAIDs - decrease effect of diuretics
6. Drugs
a) Furosemide (Lasix)
b) Ethacrynic acid (Edecrin)
c) Bumetanide (Bumex)
B. Thiazide diuretics
1. Action
a) Similar to loops
b) Block absorption of Na, Cl in distal convoluted
tubule
c) Water moves osmotically with Na and Cl
d) Action dependent on adequate renal function
2. Pharmacology / Uses
a) Onset (po) 1-2 hrs, duration 6-12; some drugs are
slow release (24-48 hrs)
b) Used for HTN, mild to moderate CHF, mobilize
mild to moderate edema with liver impairment.
3. ADRs
a) Same as Loops
b) Hyperlipidemia - some evidence that these may increase total
cholesterol ( ↑LDL) - but over time may decrease it
c) Hypersensitivity
d) Not ototoxic
4. DI
a) Same as Loops
b) Not a problem with ototoxic drugs
c) Bile acid resins can bind the drug - decrease effect of diuretic
5. Drugs
a) 8 different types - all end in Athiazide: Hydrochlorothiazide
most common
b) All given only PO - except Chlorothiazide (IV also)
c) 4 related drugs – “thiazide – like” drugs
(1) Metolazone
(a) unlike other thiazides in that it does have
good activity in pts with renal failure (low
GFR, RBF)
(b) used with Lasix resistance
(c) give 30 minutes before Lasix to increase
effect of Lasix
(2) Chlorthalidone
(3) Indapamide
(4) Quinethazone
C. Potassium Sparing Diuretics
1. Spironolactone (Aldactone)
a) Action
(1) blocks actions of aldosterone in distal tubule and
collecting duct
(2) causes excretion of Na and retention of K
(3) only small amts of Na are reabsorbed here
(4) diuresis is minimal
(5) action is delayed -- up to 48 hrs
b) Uses
(1) HTN and edema
(2) Often used with thiazides or loops - to prevent
hypokalemia
(3) To block effects of aldosterone in pts with
hyperaldosteronism
(4) Secondary aldosteronism from CHF, hepatic
disease, nephrotic syndrome
 (5) Spironolactone recently noted to have significant effect in
reducing morbidity and mortality in CHF due to aldosterone
blocking.
» Longer lasting aldosterone blocking than ACEI
» Aldosterone levels - 20 times greater in CHF due to
overproduction by the adrenal glands and reduced hepatic
aldosterone clearance.
» Drug is “cardioprotective” - aldosterone causes
myocardial and vascular fibrosis (remodeling) and direct
vascular damage – this drug reduces these adverse actions
» Should be used with ACEI and diurectics (and maybe
Digoxin) in CHF
c) ADRs
(1) Hyperkalemia
(2) Endocrine effects - menstrual irregularity,
impotence, deepening of voice, gynecomastia
2. Triamterene
a) Actions
(1) Direct inhibitor of exchange of Na and K in DCT
(2) Not through aldosterone mechanism
(3) Na excretion increased, K retained
(4) Acts more quickly
(5) Diuresis minimal
b) Uses
(1) Alone or with other diuretics to treat HTN
(2) Edema
(3) Augments other diuretics’ effect
c) ADRs
(1) Hyperkalemia
(2) N/V, leg cramps, dizziness - r/t hyperkalemia
3. Amiloride - similar to triamterene
D. Osmotic Diuretics
1. Drug
a) Mannitol (Osmitrol)
b) There are other osmotic diuretics, but only
mannitol is used for its diuretic action
c) It is used clinically
1. Action
a) Very different from other diuretics
b) Simple sugar that creates osmotic force in glomerulus
c) Is freely filtered at the glomerulus, has little
reabsorption, not metabolized, pharmacologically inert
d) Increases osmotic pressure of filtrate, water is not
reabsorbed and therefore excreted
e) Amount of diuresis r/t amount of drug
f) Little effect on excretion of electrolytes
G) Effective in reducing intracranial edema and therefore
ICP
3. Pharmacology
a) Does not cross GI endothelium
b) Given IV only
c) Does cross capillary endothelium, except in brain
4.ADRs
a) Edema
b) Fluid and electrolyte imbalances
5. Uses
a) Renal failure
b) Reduction of increased intracranial pressure
c) Reduction of intraocular pressure
Topics for Exam – Be sure you know
• Processes of filtration, reabsorption and secretion
• Identify changes in diagnostic tests associated with the diseases
covered; especially GFR, BUN, creatinine clearance
• Types of obstructions and renal stones
• Differentiate among type of infections (compare, contrast)
• All glomerulonephropathies, azotemia
• All the effects of uremia, on every system
• Causes of acute renal failure; examples of each and ATN;
nephrotic syndrome; definitions of pediatric terms/conditions
• All effects of chronic renal failure – on all systems
• Major disorders in children (causing acute and chronic disease);
differences in children
• Specifics of all diuretics – compare and contrast types