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Pharm Quiz #2 > Diuretics > Flashcards

Diuretics Flashcards

1
Q

Prescription for Hydrochlorothiazide?

A


25 mg
One tablet daily
 Do not Abbreviate

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2
Q

What are the thiazide diuretic agents?

A
  • Hydrochlorothiazide

- Chlorothiazide

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3
Q

Where do the thiazide diuretics work?

A 
o	Distal convoluted tubule
	Sulfonamide molecule
•	Worry about allergies to sulfur drugs
	Cells impermeable to water
	10% sodium reabsorption
•	Na+/Cl- transporter sensitive to thiazides
•
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4
Q

Indication for Hydrochlorothiazide?

A

 Management of mild-to-moderate hypertension

 Treatment of edema in heart failure and nephrotic syndrome

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5
Q

Indication for Chlorothiazide?

A

 Management of hypertension

 Adjunctive treatment of edema

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6
Q

Indication for Methyclothiazide?

A
  • Management of hypertension

- Adjunctive therapy of edema

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7
Q

What are the “Ceiling” diuretics for the thiazide diuretics?

A

Increasing the dose beyond the normal dose does not increase diuretic effect

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8
Q

What are the effects for the thiazide diuretics?

A 
o	Increased excretion of sodium and chloride
o	Loss of potassium
o	Loss of magnesium
o	Decreased urinary calcium excretion
o	Reduced peripheral vascular resistance
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9
Q

What are the kinetics for the thiazide diuretics?

A

o 1 to 3 weeks to produce a stable reduction in blood pressure  lose plasma volume so BP drops
o Then theory is you get direct vasodilation of arterial smooth muscle for long-term control

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10
Q

What are the adverse drug reactions of the thiazide diuretics?

A 
o	Hyponatremia (rare)
	Hypovolemia leading to increase in ADH, diminished diluting capacity of kidney and increased thirst
	Limit water intake and use lower doses
o	Hyperuricemia  gouty arthritis
o	Volume depletion
	Orthostatic hypotension, dizziness
o	Hypercalcemia
o	Hypersensitivity
	Very rare- bone marrow suppression, dermatitis, necrotizing vasculitis, interstitial nephritis
o	Hyperglycemia
	Elevated blood glucose levels- harm or hype
o	Hyperlipidemia
	Elevated TC, LDL – harm or hype
o	Hypokalemia
	How low will I go?
o	NEED to get BMP on regular basis to check electrolytes (usually not a big deal though)
o
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11
Q

What is the main thiazide-like diuretic?

A

• Chlorthalidone

o Long duration of action

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12
Q

Info about Metolazone?

A
  • More potent than the thiazides

* Causes sodium excretion even in advanced renal failure

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13
Q

Info about Indapamide?

A

• Low doses- significant antihypertensive effect with minimal diuretic effect
• Gastrointestinal tract excretion- less likely to accumulate in patients with renal failure
•

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14
Q

Prescription for Chlorthalidone?

A

50 mg

One tablet daily

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15
Q

What was Chlorthalidone noted as ?

A

Chlorthalidone noted as superior to other agents such as lisinopril, amlodipine or doxazosin

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16
Q

When may the addition of a thiazide to a loop diuretic be helpful?

A

refractory edema in heart failure, cirrhosis, nephrotic syndrome and renal failure

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17
Q

What are the loop diuretics?

A
  • **Furosemide
  • Bumetanide
  • Torsemide
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18
Q

Prescription for Furosemide?

A

40 mg

One tablet twice a day

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19
Q

Where/how do the loop diuretics work?

A 
o	Ascending Loop of Henle
	Sulfonamide molecule
	Cells impermeable to water
	25 to 30% sodium reabsorption
•	Na+/K+/2Cl- cotransporter
  • “High-ceiling diuretics
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20
Q

What are the effects of the loop diuretics?

A

o Increased excretion of sodium and chloride
o Loss of potassium
o Loss of magnesium
o Increased urinary calcium excretion
o Hypocalcemia avoided as most calcium reabsorbed in distal convoluted tubule
o Reduced renal vascular resistance/ increased renal blood flow
o Result of increased prostaglandin synthesis from loop diuretic use

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21
Q

What is the Diff in IV to PO for furosemide?

A

~ 50% bioavailability compared to the others, so if 40 mg IV is good, must give 80 mg oral on DC

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22
Q

Indications for furosemide?

A

 Management of edema associated with heart failure and hepatic or renal disease
 Acute pulmonary edema
 Treatment of hypertension (alone or in combination with other antihypertensives)

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23
Q

Indications for Bumetanide (Bumex™)?

A

Management of edema secondary to heart failure or hepatic or renal disease (including nephrotic syndrome)

24
Q

Indications for Torsemide (Demadex™)?

A

 Management of edema associated with heart failure and hepatic or renal disease (including chronic renal failure)
 Treatment of hypertension

25
Q

What is the main use for loop diuretics?

A 
•	Main use in treatment of states of volume excess like:
o	Heart failure
o	Nephrotic syndrome
o	Acute and chronic renal insufficiency
o	Cirrhosis
26
Q

What is the onset of the loop diuretics?

A

o Relatively rapid with symptom relief within hours to days

27
Q

What are the adverse drug reactions of the loop diuretics?

A 
o	See thiazides, only electrolyte loss may be more profound
	Potassium depletion (supplementation)
	Magnesium depletion (supplementation)
o	Ototoxicity
o	ethacrynic acid, aminoglycoside use
28
Q

What are the Potassium Sparing diuretics? (agents)

A
  • Triamterene, amiloride

- Spironolactone/eplerenone

29
Q

What are the sodium channel blockers of the Potassium Sparing diuretics?

A
  • Triamterene, amiloride
  • 3 to 5% sodium reabsorption at this site
  • Used with HCTZ usually
30
Q

What are the aldosterone antagonists of the Potassium Sparing diuretics?

A
  • Spironolactone/eplerenone
  • Blocks stimulation of the Na+/K+ exchange sites - - in collecting tubule (1 to 3% net diuretic effect)
  • Sodium lost for diuretic effect but potassium retained
  • Spironolactone- hormonal effect
  • Works with high levels of aldosterone and vice versa
31
Q

Indication for amiloride?

A

 Adjunctive treatment with thiazide diuretics or other kaliuretic-diuretic agents in congestive heart failure or hypertension to help restore normal serum potassium levels in patients who develop hypokalemia
 Prevent development of hypokalemia in patients who would be exposed to particular risk if hypokalemia were to develop

32
Q

Indication for Triamterene?

A

Alone or in combination with other diuretics in treatment of edema and hypertension; decreases potassium excretion caused by kaliuretic diuretics

33
Q

Indication for Spironolactone?

A

 Management of congestive heart failure
 Cirrhosis of the liver accompanied by edema and/or ascites
 Nephrotic syndrome

34
Q

Indication for eplerenone?

A
  • To improve survival of stable patients with left ventricular systolic dysfunction and clinical evidence of congestive heart failure after an acute myocardial infarction
  • Treatment of hypertension
35
Q

o Adverse Drug Reactions for Triamterene and amiloride?

A

 Leg cramps
 Increased blood urea nitrogen
 Potassium retention
 Increased uric acid

36
Q

Adverse Drug Reactions for Aldosterone antagonists?

A

 Gastric upset (spironolactone)
 Gynecomastia (males)
 Menstrual irregularities (females)

37
Q

Potassium sparing diuretics are contraindicated when?

A

• Generally useful in heart failure
o ACC/AHA guidelines- Class II-IV heart failure
o Contraindicated in baseline serum creatinine above 2.5 mg/dL and serum potassium greater than 5 mEq/L

38
Q

Prescription for Amiloride?

A

10 mg

One tablet daily

39
Q

Prescription for spironolactone?

A

25 mg
One tablet twice a day

  • For HTN
40
Q

What is the Osmotic Diuretics?

A

Mannitol

41
Q

How to write a prescription for Mannitol?

A

GET INTENSTIVIST INVOLVED!

42
Q

What is the Intravenous administration for Mannitol?

A

 Inhibits sodium reabsorption in proximal convoluted tubule and Loop of Henle

43
Q

What is the Inpatient setting for Mannitol?

A

Reduction of intracranial pressure

 Reduction of ocular pressure

44
Q

MOA for Potassium supplementation?

A

electrolyte replenishment

45
Q

ADR for Potassium supplementation?

A
  • asymptomatic hyperkalemia (6.5 to 8 mEq/L; ECG changes

- gastrointestinal symptoms

46
Q

Note for Potassium supplementation?

A

watch for patients with renal insufficiency (K+ can rise)

47
Q

Class drug for Potassium supplementation?

A

potassium chloride (K-Dur™, Slow-K™)

  • IV or oral
  • When K+ in low 3’s –> give oral
  • When K+ < 3, then give IV!
48
Q

How many milliequivalents of K+ to bump up serum levels?

A

20-40 milliequivalents

49
Q

What are the most common adverse effects of the diuretics?

A

Fluid and electrolyte abnormalities most common adverse effects:

  • 50% of patients receiving a loop diuretic experience potassium levels less than 3.5 mEq/L
  • Electrolyte changes occur in first few weeks of therapy and potassium depletion is not progressive with continued treatment
50
Q

How often do you monitor electrolyte levels in diuretcs?

Other important measures?

A
  • Electrolytes at baseline, in 1 week, in 1 month and periodically
  • Volume status assessed at baseline and periodically
  • Record weight at home (lose water weight)
51
Q

Application for HTN?

A
  • Hydrochlorothiazide versus ***chlorthalidone

- As good as ACE inhibitors or calcium channel blockers

52
Q

Application for Heart Failure?

A
  • Offset to increased plasma volume

- Be careful!

53
Q

Application for Kidney Disease?

A
  • Address volume retention between dialysis treatments

- Combination therapy

54
Q

Special Considerations in Geriatrics?

A
  • Fall in GFR diminishes diuretic effect with thiazides

- SHEP trial still showed that isolated systolic -hypertension would respond to low dose chlorthalidone

55
Q

Special Considerations in Pediatrics?

A
  • Thiazides, spironolactone have been safely used in children
  • Avoid furosemide in premature infants with respiratory distress syndrome
  • Side effects may not be as apparent or reportable based on patient age
  • Watch for changes in personality, eating or sleeping patterns or restlessness and investigate promptly
56
Q

Summary of Diuretics?

A
  • Diuretics are used to reduce fluid volume, to effect some direct vasorelaxation and thus reduce blood pressure
  • Electrolytes can be lost while using diuretics and may need to be replaced.
  • In simple cases of hypertension, diuretics are first-line therapy
  • Diuretics are a mainstay of heart failure treatment (when volume is a problem)

Pharm Quiz #2 (6 decks)

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