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Diuretic Drugs

P. Sutton, MS, RN
Nursing 2 DHSON
Pharmacology Chapter 26

Diuretics
Drugs that accelerate urine
formation
Remove sodium and water from the
body
Most commonly prescribed drugs
Hypotensive activity
Exert effect on nephron
GFR used to adjust doses

Advantages
Relatively low in cost
Favorable safety profile

Problems
Metabolic adverse effects that result
from excessive fluid and electrolyte loss
Effects are usually dose related and
controlled with dose titration/adjustment
See Table 26-1 pg 405

LOOP DIURETICS
Potent diuretics
Chemically related to sulfonamide
antibiotics
Contraindicated in sulfa allergic
patients
Commonly given to patients with
sulfa allergies
Nurse to be aware of potential for
allergic reactions

Mechanism of Action

Renal, cardiovascular and metabolic effects


Act on loop of Henle
Block chloride and sodium resorption
Believed to activate renal prostaglandins
Beneficial hemodynamic effects
Useful when rapid diuresis is needed
Often single dose is effective
Major adverse effects: electrolyte
imbalance

Indications
Manage edema associated with heart
failure and hepatic or renal disease
Control hypertension
Increase renal excretion of calcium
Heart failure resulting from diastolic
dysfunction

Contraindications
Drug allergy
Also consider drug allergy to
sulfanamides
Hepatic coma
Severe electrolyte loss

Adverse Effects
CNS dizziness, headache, tinnitus,
blurred vision
GI Nausea, vomiting, diarrhea
Hematologic agranulocytosis,
thrombocytopenia, neutropenia
Metabolic hypokalemia,
hyperglycemia, hyperuricemia
Drug Interactions- See Table 26-3 pg
407

Currently Available Loop


Diuretics

Bumetanide 1mg
Ethacrynic Acid 50mg
Furosemide 40mg
Torsemide 10mg

Furosemide (Lasix)
Most commonly used loop diuretic
Has all therapeutic effects of loop
diuretics
Used to manage
Pulmonary edema
Liver disease
Edema assoc with heart failure Ascites
Nephrotic syndrome
HTN

Onset:
Peak:
Half Life
Duration

IV
IV
IV
IV

5min PO 30-60min
15min PO 1-2 hr
1-2 hr PO 1-2 hr
2hr
PO 6-8 hrs

POTASSIUM SPARING
DIURETICS
Referred to as aldosterone inhibiting
diuretics
Spironolactone is competitive
antagonist of aldosterone
Cause sodium and water to be
excreted while retaining potassium

Currently Available Drugs in the


Class
Amilorid (Midamor)
Spironolactone (Aldactone)
Triamterene (Dyrenium)

Mechanism of Action
Work in collecting ducts and distal
convoluted tubules
Interfere with sodium-potassium
exchange
Spironolactone binds to aldosterone
receptors
Amiloride and triamterene do not
bind to aldosterone receptors, but
inhibit aldosterone induced and basal
sodium reabsorption

Often prescribed for children with


heart failure
Compete with thiazides and loop
diuretics
Generally used as adjuncts to
thiazide treatment

Indications
Applications vary depending on the
drug
Spironolactone and Triamterene used
to treat hyperaldosteranism and HTN
Spironolactone and cardioprotective
benefits
Amiloride less effective for long term
use
Amilrode useful in metabolic alkalosis
and primarily used to treat heart

Adverse Effects
Significant effects are specific to
individual drugs
Spironolactone
Gynecomastia
Amenorrhea
Irregular menses
Postmenapausal bleeding

Triamterene
Reduces folic acid levels and causes
renal calculi and urinary casts
Precipitates megoblastic anemia
(rare)
Hyperkalemia can result when
Potassium Sparing Diuretics are used
in combination with each other and/or
other Potassium Sparing drugs (ie
ACEIs)

Interactions
Concurrent use of potassium sparing
diuretics and lithium
ACEIs
Potassium Supplements
NSAIDS

Amiloride (Midamor)
Used in combination with loop or
thiazide diuretics to treat heart
failure
Hyperkalemia may occur when taken
alone
Use in caution for pts with renal
impairement or DM and in the elderly
Weak antihypertensive properties
Available in oral form only
Available in comb for w/

Onset: 2 hrs
Peak 6-10 hrs
Half Life 6-9 hrs
Duration 24 hrs

Spironolactone
Synthetic steroid that blocks aldosterone
receptors
Used in high doses to treat ascites
Hyperkalemia common complication
Frequent K+ monitoring
Most commonly ordered Potassium Sparing
Diuretic for children w/ heart failure
Available in oral form only and in comb
with hydrochlorothiazide

Onset 1-3 days


Peak 2-3 days
Half life 13-24 hrs
Duration 2-3 days

Triamterene
Similar to amiloride
Acts directly on distal renal tubule of
nephron
Depresses sodium resorption and
excretion of potassium and hydrogen
Available in oral form only
Available in combination form with
hydrochlorothiazide

Onset 2-3 hrs


Peak 6-8 hrs
Half life 2-3 hrs
Duration 12-16 hrs

THIAZIDES AND THIAZIDE-LIKE


DIURETICS
Primary site of action is distal confoluted
tubule
Result in osmotic water loss
Cause direct relaxation of arterioles
Beneficial hemodynamic effects
Effect diminishes as renal function decreases
Major adverse effect from electrolyte imbal
Metabolic disturbances: hyperlipidemia,
hyperglycemia and hyperuricemia

Indications

Edema of various origins


Idiopathic hypercalcemia
Diabetes Insipidus
Hypertension
Adjunct drugs in management of
heart failure and hepatic cirrhosis
Can be used alone or in combination
with other drugs

Contraindications

Known drug allergy


Hepatic coma (metolazone)
Anuria
Severe renal failure

Adverse Effects Major Effects r/t electrolyte and


metabolic distrubances:
Reduced K+
Elevated Ca
Elevated Lipids
Elevated Glucose
Elevated Uric Acid

Other Less Common Adverse Effects

GI disturbances
Skin rashes
Photosensitivity
Thrombocytopenia
Pancreatitis
Cholecystitis

Toxicity
Overdose leads to electrolyte imbalance from
hypokalemia
Anorexia
Nausea
Lethargy
Muscle weakness
Mental confusion
Hypotnesion
Treatment for Toxicity is Electrolyte
Replacement

Interactions

Corticosteroids
Diazoxide
Digitalis
Oral hypoglycemic
Excessive licorice consumption

Hydrochlorothiazide
(HydroDIURIL)
Considered the prototypical thiazide
diuretic
Commonly prescribed and
inexpensive drug
Safe and effective
Used in combination with other drugs
Available in oral form only
Ceiling Effect

Onset 2 hr
Peak 4-6 hrs
Half life 5-15 hrs
Duration 6-12 hrs

Metolazone (Zyroxolyn)
Thiazide-like diuretic
More potent than thiazide drugs
Greater potency most visible in pts
with renal dysfunction
Advantage: remains effective with
low creatinine clearance
May be given in combo w/ loop
diuretics
Available in oral form only

Onset 1 hr
Peak 1-2 hrs
Half life 6-20 hrs
Duration 24 hrs