CV & Renal: Diuretics Flashcards by Anthony Carli

Which type of diuretic?

steep slope on dose response curve
dose-dependent diuresis throughout therapeutic range

Loop diuretics

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Which type of diuretic?

Flat dose-response curve
limited maximum response

Thiazide diuretics

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Rank the 4 types of diuretics in terms of diuretic effect…

Loop&raquo_space; thiazide&raquo_space; CA Inhibitors > K+ Sparing

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Which diuretics have greatest effect on increasing NaCl excretion?

Loop monotherapy

Loop + Thiazide

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Which diuretics have the greatest effect on Sodium Bicarb excretion?

CA inhibitors

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Which diuretics have the greatest effect on increasing excretion of potassium?

loops + thiazide

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The arterial end of capillary bed favors shift of fluid…

out of vessels

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The venous end of capillary bed favors shift of fluid…

into vessels

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What three physiologic effects promote edema?

↑ hydrostatic P
↑ colloidal P
Inadequate lymphatic drainage

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What causes an ↑ hydrostatic P which could favor edema?

↑ arterial or venous pressure

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What causes an ↑ colloidal P that would favor edema?

↓ osmotic gradient via Na+ & H2O retention

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The following conditions are associated with what physiologic process?

HF
Hepatic cirrhosis
Nephritis, nephrosis, renal damage from HTN
Diseases of steroid hormone secretion
Pre-eclampsia
Toxemia
Anaphylaxis and hypersensitivity reactions

Edema

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Which section of the renal tubule?

Drugs:
Acetazolamide
Osmotic Agents

Reabsorbs:
NaHCO3
NaCl

PCT

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Which section of the renal tubule?

Drugs:
Osmotic Agents

Reabsorbs:
H2O

Descending LOH

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Which section of the renal tubule?

Drugs:
Loop Diuretics

Reabsorbs: 
2Cl-
K+
Na+
Mg2+
Ca2+

Thick Ascending LOH

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Which section of the renal tubule?

Drugs:
Thiazides

Reabsorbs:
NaCl
Ca2+ (via PTH)

Early DCT

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Which section of the renal tubule?

Drugs:
Osmotic Agents
Aldosterone Antagonists
ADH Antagonists

Reabsorbs:
NaCl (via Aldo)
Secretes:
K+
H+
H2O (via ADH)

Late DCT & CD

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Osmotic agents act on what three parts of the renal tubule?

PCT, Desc. LOH, CD

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Acetazolamide acts on what part of the renal tubule?

PCT

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Loop diuretics act on what part of the renal tubule

Thick ascending limb of LOH

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Thiazide diuretics act on what part of the renal tubule?

Early DCT

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Aldosterone antagonists act on what part of the renal tubule?

Late DCT

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ADH antagonists act on what part of the renal tubule?

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What effect do thiazide diuretics have on calcium?

↑ Ca Reabsorption

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What effect do loop diuretics have on calcium and magnesium?

↑ Ca & Mg Excretion

Acidic drugs compete with ______ for excretion.

uric acid

The "--olamide" suffix refers to which class of diuretics?

CA inhibitors

Inhibition of carbonic anhydrase leads to a decreased production of what?

H2CO3

↓ H2CO3 Production from carbonic anhydrase inhibition affects what channel that leads to ↓ Na+/H2O reabsorption?

↓ H+/Na+ Exchange (lumen to PCT cells)

This diuretic is indicated for: Glaucoma Alkalizing Urine Metabolic Alkalosis Acute mountain sickness

CA inhibitors (--olamides)

What are two contraindications/precautions for CA inhibitors?

hepatic cirrhosis | sulfa

Which diuretics have the following adverse effects? - hyperchloremic metabolic acidosis - hypokalemia (acidosis = K ECF --> K ICF) - hyperuricemia

CA inhibitors (--olamide)

describe the effectiveness of CA inhibitors over several days...

decreases

Furosemide and Ethacrynic Acid are which type of diuretic?

Loop

This class of diuretics blocks NKCC2 and ↑ Prostaglandin Production

Loop diuretics

Which class of diuretics has the following indications? HF Pulmonary Edema Hypercalcemia Impaired renal fxn edema

Loop Diuretics

What three drugs cannot be combined with loop diuretics?

NASAIDs/COX inhibitors (requires PGs), aminoglycosides (ototoxic), digoxin (decreased K --> digoxin toxicity)

Overzealous use of loop diuretics is dangerous with what three conditions?

cirrhosis, borderline renal failure, HF

Which loop diuretic is a sulfa drug?

furosemide

The following adverse effects describe which class of diuretics? - hypokalemic metabolic acidosis - Hypocalcemia - hypomagnesemia - hyperuricemia - irreversible ototoxicity

Loop diuretics

Ototoxicity is worse worse with ______ is combined with ______

ethacrynic acid + aminoglycosides

Which 3 drugs are thiazide diuretics?

hydrochlorothiazide, metolazone, indapamide

How do thiazide diuretics inhibit sodium reabsorption in the early distal tubule?

inhibit Na/Cl Cotransporter

Thiazide diuretics depend on synthesis of...

prostaglandins

Which class of diuretics has the following indications? - HTN - HF - Nephrolithiasis - Nephrogenic DI

Thiazides

These diuretics... - contain sulfa - increase hyperglycemia

Thiazide diuretics

What three drugs must be used with caution when administering thiazides?

digitalis (hypokalemia induced toxicity) NSAIDs (decreased PGs) Lithium (toxicity)

Thiazide diuretics are acidic, meaning they should be used with caution in what condition?

hyperuricemia

Thiazide diuretics hyperpolarize the cell, leading to relaxed smooth muscle and vasodilation. What does thiazide act on to make this happen?

Increased potassium ATPase channel opening

Thiazide diuretics have synergistic effects with which three drugs for HTN tx?

ACE, ARB, BB

What effect does thiazide have on calcium excretion?

decreased calcium excretion due to increased calcium channel activity

Thiazide diuretics increase calcium reabsorption by increasing PTH dependent calcium channel activity. Is this helpful in tx of osteoporosis?

Which class of diuretics have the following adverse effects? - hyperglycemia - hypokalemic metabolic acidosis - hyperuricemia - hypomagnesemia - increased lipids

Thiazide diuretics

The following mechanism describes which adverse effect of thiazide diuretics? ↑ K+ & H+ secretion at DCT → volume contraction → RAAS → ↑ Aldo → ↑ K+ secretion

hypokalemic metabolic acidosis

What causes increased lipids with thiazide administration?

low insulin secretion

This drug is indicated when GFR is < 20

metolazone (thiazide)

This drug has pronounced vasodilation and doesn't increase lipids... it is metabolized 50/50 in the liver and kidney

indapamideb (thiazide)

This class of drugs interferes with sodium reabsorption in DCT without compromising potassium...

potassium sparing diuretics

Which drug has the following mechanism? Competitive Aldo. antagonism leading to: ↓ Na+ channels ↓ Na+ conductance → hyperpolarization → ↓ K+ Excretion ↓ Na+/K+ ATPase activity → ↓ K+ Excretion

spironolactone

high doses of spironolactone lead to inhibition of what two receptor types?

glucocorticoid and sex hormone receptors

This diuretic has the following unique indications: Hyperaldosteronism Hirsutism

Spironolactone

What are two contraindications for spironolactone administration?

use with ACE/ARBs (hyperkalemia) Gynecomastia

Which potassium sparing diuretic has the following characteristics? Selective Aldosterone Receptor Antagonist P3A4 Metabolism ↓ Endocrine SFx, ↓ steroid receptor affinity

Eplerenone

Which two diuretics have the following mechanism? Directly inhibits aldosterone-sensitive Na+ channel → ↓ K+ excretion

Amiloride and Triamterene

Which diuretic has the following indications? - DOC for lithium induced DI - non-acid diuretic safe in hyperuricemia - combo w/ K losing diuretics

amiloride and triamterene

Amiloride and triamterene are contraindicated in what condition?

hyperkalemia (burn patients)

The following are what class of diuretic? Mannitol Isosorbide Glycerin Urea

osmotic

Which drugs have the following characteristics? IV only pharmacologically inert Filtered, not absorbed

osmotic diuretics

Which diuretic class has the following unique indications? - acute renal failure prophylaxis - ↓ IOP - ↓ Intracranial pressure in brain edema - Protect kidney from nephrotoxins

Osmotic diuretics

Excessive administration of osmotic diuretics can have what effect?

ECF volume expansion

Osmotic diuretics are contraindicated in what condition?

This drug is a synthetic ADH that primarily works on V2 receptors

Desmopressin

What class of drug is desmopressin?

ADH agonist

Desmopressin is used in what situation?

tx of central DI ↓ H2O Excretion

"-vaptan"s are what drug class?

ADH Antagonists

Which drug has the following mechanism? Non-peptide V1a and V2 receptor antagonist leads to increased sodium concentration and water clearance

Conivaptan

Which drug class is indicated for euvolemic or hypervolemic hyponatremia?

ADH antagonists (vaptans)

What are three characteristics that differentiate tolvaptan from conivaptan?

1. non-peptide V2 antagonist 2. PO admin 3. can be continued outpatient