DSA01 Oglesby Diuretics

Drug
MOA
Loop Diuretics
Block Na/K/2Cl
Furosemid
active co-transport
e
of ions in the
ascending loop of
Henle
o Electrically neutral
transport
o K+ has a second
transporter for
reabsorption in DCT
o Net effect: more
Na held in lumen
w/o retention of
K+ in lumen
Torsemide
w/o diuretics back
diffusion of K+:
membrane is
permeable to K+ so it
follows [ ] back into
lumen
o Lumen (+)
charged
o Drives divalent
cations (Ca2+ and
Mg2+) out of lumen
via pracelular
pathway
W/ diuretic:
Ca2+/Mg2+ loss
o PTH compensates
for loss of calcium
thus
hypomagnesemia
more freq.

SE

Clinical Uses

Notes

water and
electrolyte loss
Hypokalemia
o Watch CHF pts on
digoxin
o K+ and H+ lost in CD
or DCT d/t excess Na+
arriving in the lumen of
the CD
Hypokalemic metabolic
alkalosis
o s/t hypokalemia +
enhanced quantities of
Na at CD
Hyperuricemia:
hypovolemia enhances
reabsorption of urate at
proximal tubule. Watch pts
w/ hx/FMHx gout
Hypomagnesemia: more
profound than
hypocalcemia
Ototoxicity: usu
reversible, watch out for
pts also taking
aminoglycosides abx
Hypovolemia big SE.
very easy to get too much
fluid loss
Drug interactions:
o Aminoglycosides:
Ototoxicity
o Digitalis
(digoxin/digitoxin):
likelihood of
arrhythmias

Used in emergency
and chronic tx of
edematous states,
ven w/ low GFR (loops
actively secreted into
lumen in PCT)
o Cardiac: MI, CHF
o Pulmonary Edema
o Hepatic Ascites: s/t
cirrhosis. Both
transudative and
exudative. Improves
morbidity not
mortality
o Renal failure
Used in Hypercalcemia
d/t:
o Hyperparathyroidism
o Malignancy
o Temp. measure to
hyper Ca (combined
w/ saline) b4 surgery
Used in Hypertension
(NOT essential HTN)
o Only if thiazides
didnt work (HTN in
presence of chronic
renal failure; mech is
vol. reduction)
Used in Hyperkalemia
o s/t insufficient renal
excretion
o czes loss of RMP
(cardiac problems)
Anion poisoning:
fluoride, iodide, bromide

Prototype Loop diuretic

Distal tubule is the
important site for
regulating
elimination of K+
Extremely efficacious.
fractional Na excretion
to 20-25% of glomerular
filtrate
o lots of salt and water
can be excreted w/
loop diuretics
Also diminish interstitial
fluid osmolality of
medullary fluid
o More Na in lumen
holding water in
o Less Na in
interstitium pulling
water out.
Esp furosemide:
Vasodilation: acutely
systemic venous
capacitance
o Requires intact
kidneys
o PG2 mediated
o L ventricular filling
press: useful in
pulm. Edema
o Happens before
significant diuresis
begins
Torsemide: Convenience
of once daily dosing

Drug

Thiazides
Hydrochlor
o-thiazide

Chlorthalid
one

MOA

SE
o Sulfonylureas (DM II):
hyper-glycemia
o Li for bipolar tx: Na
preferentially excreted
instead. Can reach Li
toxicity lvls
o NSAIDs: reduce
glomerular filtration
o Thiazides: additive
interaction.
Synergism
Watch for allergic rxn in
pts w/ sulfa allergy

Clinical Uses

Notes

Inhibit Na/Cl
cotransporter in
DCT (perhaps also
PCT)
Slow onset; long
lasting
o Have to be filtered
to be active
Less efficacious than
loops

Hypokalemia: same as
above
o Watch digoxin
Hypokalemic metabolic
alkalosis (same as above)
Hyperurecemia
Hyponatremia (w/ or w/o
hypovolemia)
o Usu w/o hypovolemia
o Increased negative free
water clearance (more
Na+ lost than water)
o More salt than water
loss. Water loss that is
non-ADH dependent.
Common in elderly and
frail pts. Or stable pts
when normal Na intake
is .
Hyperglycemia:
o insulin secretion
may unmask latent
DM)
o usu clnically important
only at high dose

Hypertension (10-15
mmHg )
o BV (vol. returns to
near nl over 6-8 wks,
but anti-HTN effect
remains)
o reduce vascular
resistance by
relaxation of
arterioles (Na+
vessel stiffness, so
Na+ relaxes
arterioles)
o responsiveness of
arterioles to NE (also
b/c of Na+)
Diabetes Insipidus
(ADH dz): tremendous
fluid loss and thirst
o Amount of fluid loss
per day can be by
50% per day***
Non-emergency
edematous states
(cyclic edema a/w

Chlorthalidone used
most frequently

Drug

MOA

Thiazide-Like
Indapamid
e

Metolazon
e

Similar to thiazide
Probably slight PCT Na
blockade
Same as above

Drug
MOA
K+ Sparing Diuretics
Spironolac Aldosterone
tone
antagonist
Blocks stimulus of
nuclear message
produced by
aldosterone
stimulus for Na/K
ATPase activity
tremendously
driving force for
reuptake of Na+

Eplerenon
e

SE
o usu reversible w/
correction of
hypokalemia
Allergic reactions
Erectile dysfunction

Clinical Uses
menstrual cycle)
Hypercalciuria
o Volume contraction
czed by thiazides
stimulates PCT
reabsorption of Ca2+

Also have sulfonamide

structure allergic
reactions
Same as above

Saved to use in
combination w/ loops
when loops arent
working enough
Same as above

Notes

SE

Clinical Uses

Notes

Hyperkalemia
o Esp w/ ACE inhibitors,
NSAIDS, beta blockers
o MC when coadministered w/ K+
supplement, which isnt
rational
Anti-androgen effect
(steroid structure leads to
competitive inhibition of
androgen receptors
o Gynocomastia
(irreversible)
o impotence
Intended in development to
be an aldosterone
antagonist w/ no antiandrogen effects
SE profile shows

Not very efficacious

diuretics by themselves
o By the collecting
tubules, not much
Na as compared to
amount at
glomerulus
Heart failure
Mainly Used to
prevent K+ loss czed
by other diuretics
o Counteract this SE of
thiazides and loops
o Hyperaldosteronism
syndromes (rare)

Documented to have
efficacy in improving
morbidity/ mortality in
end stages of heart
failure


Triametere
ne
Amiloride

Inhibit Na+ transport in

distal tubules
Reuptake of Na+ in
distal tubules is
blocked directly

Carbonic Anhydrase inhibitors

Acetazola
Inhibit CA at two sites:
mide
in lumen as well as in
cells of PCT
Inhibit formation of H+
and HCO3- from CO2
and H2O and vice
versa
Diminish reabsorption
of HCO3- and Na+
Result: Urine is basic
and blood winds up w/
excess acid
academia

gynocomastia
Consequently little
difference from
spironolactone
GI (Nausea, vomiting)
Dizziness
Leg cramps: Charlie horse
type phenomenon.
Unknown mechanism of
how this happens
Nephrolithiasis
(triamterene)

Metabolic acidosis
o K+ depletion
Renal stones
Hypersensitivity
reactions (rare)
o Rash
o Fever
o Bone marrow
suppression

Seldom used as
diuretics
o Metabolic acidosis (
plasma bicarb)
o Rapid refractoriness
Glaucoma
o
o
o

production of aqueous
humor
formed by secretion of
bicarb from blood w/ water
following
given topically (drops). Do
not gain access to systemic
circulation in high enough
dose to effect kidneys.
Primary use of these
agents -- drugs ending in
zolamide

Alkalization of urine
o

o
o
o

Useful in nephrolithiasis czed

by uric acid and cysteine
stones (both poorly soluble
in acidic pH)
Uric acid stones MC. pH to
6-6.5.
Too aggressive pH
promotes calcium stones
DO NOT use in aspirin
toxicity/poisoning

Mountain sickness
PROPHYLAXIS not tx
Epilepsy

Osmotic Diuretics

Tremendous tolerance
after a week or so that's
why its not really ever
used.
Discovered during sulfa
abx drug research

Mannitol

Non-electrolytes, but
HIGHLY POLAR
o Confined to ECF
(dont enter cells)
Freely filterable at
glomerulus
Not reabsorbed
Provide a higher
solute load in the
nephron -- ostmotic
pressure in nephron
water reabsorption
o Leads to more
water than Na loss
Poorly absorbed, given
IV

Transient expansion of
ECF volume,
hyponatremia
o Mannitol is distributed in
the extracellular
compartment and draws
water from the
intracellular
compartment
o Can result in volume
overload in the vascular
tree, w/ cardiac failure
and/or pulmonary
edema. Do not use these
agents in pts w/
cardiac capacity
Headaches, nausea,
vomiting

Prophylaxis of renal
failure
o More retention in
nephron and
elimination of fluid
o Not their nl use
o Usu taken care of by
loop + thiazide like
diuretics combo
the pressure and
volume of intraocular
fluid and CSF
o used in
emergency tx of
e.g. head injuries
Hemodialysis