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Diuretics Flashcards

1
Q

Diuretic Drugs

A

Accelerate the rate of urine formation

Removal of sodium and water

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2
Q

Mainstay of therapy for the treatment and prevention of

A

Hypertension & heart failure

Prevention of kidney damage during acute kidney injury

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3
Q

Sodium pathophysiology in the nephron

A

In the nephron, where sodium goes, water follows.

-60 to 70% of sodium and water is returned to the bloodstream by the proximal convoluted tubule.

-20 to 25% of all sodium is reabsorbed into the bloodstream in the ascending loop of Henle.

-5 to 10% is reabsorbed in the distal convoluted tubule.

-Collecting duct is the final common pathway for the filtrate that started in the glomerulus.

-If water is not absorbed, it is excreted as urine.

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4
Q

The Nephron & Diuretic’s sites of action

A

Afferent and efferent arterioles
Glomerulus
Proximal CT (Mannitol) (Acetazolamide)
Descending Loop (Mannitol)
Ascending Loop (Furosemide)
Distal CT (Thiazide) (Potassium sparring)
Collecting duct (Potassium sparring)

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5
Q

List the 5 Diuretics and their important medications

A

Carbonic anhydrase inhibitors (Canada primary use is for glaucoma)
-acetazolamide

Loop diuretics
-furosemide
-bumetanide
-ethacrynic acid

Osmotic diuretics
-mannitol (Osmitrol®)
-Urea
-Organic acids
-Glucose

Potassium-sparing diuretics
-amiloride (Midamor®)
-spironolactone (Aldactone®)
-triamterene
-triamterene in combination with hydrochlorothiazide

Thiazide and thiazide-like diuretics
-Thiazide diuretics
~hydrochlorothiazide (Urozide®)
-Thiazide-like diuretics
~metolazone (Zaroxolyn®)
~chlorthalidone
~indapamide

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6
Q

acetazolamide (Acetazolam®)

  1. Drug class
  2. Benefit
A

Carbonic Anhydrase Inhibitor

Oral and parenteral forms

Potential benefits may warrant use in pregnant women despite potential fetal risks

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7
Q

Carbonic Anhydrase Inhibitors: Mechanism of Action

  1. Enzyme carbonic anhydrase:
  2. Carbonic anhydrase inhibitors:
A

Proximal tubules

For NA and water to be reabsorbed in blood, hydrogen must be exchanged for it. Without H, this process cannot occur (NA and water will be excreted)

Enzyme carbonic anhydrase: helps to make H+ ions available for exchange with sodium and water in the proximal tubules.

Carbonic anhydrase inhibitors: block the action of carbonic anhydrase, thus preventing the exchange of H+ ions with SODIUM and WATER.

Inhibition of carbonic anhydrase reduces H+ ion concentration in renal tubules.

As a result, there is increased excretion of bicarbonate, sodium, water, and potassium. (CAIs reduce formation of H and bicarbonate)

Resorption of water is decreased, and urine volume is increased.

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8
Q

Carbonic Anhydrase Inhibitors: Indications

  1. Adjunct for?
  2. Used with ____ to…
  3. Treatment of (3)
A

Adjunct drugs for: Open-angle glaucoma and secondary glaucoma (to increase outflow of aqueous humour)

Used with miotics to lower intraocular pressure before ocular surgery

Treatment of: Edema, secondary to heart failure & High-altitude sickness & Epilepsy

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9
Q

Carbonic Anhydrase Inhibitors: Contraindications

A

Known drug allergy
Hyponatremia
Hypokalemia
Severe kidney or liver dysfunction
Adrenal gland insufficiency
Cirrhosis

CAIs can increase glucose levels, R & M acidosis

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10
Q

Carbonic Anhydrase Inhibitors: Adverse Effects

A

Acidosis
HYPOkalemia
Drowsiness
Anorexia
Paresthesias
Hematuria
Urticaria
Photosensitivity
Melena (blood in the stool)

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11
Q

Carbonic Anhydrase Inhibitors: Interactions

A

Digoxin toxicity due to hypokalemia

Corticosteroids- cause hypokalemia

Increased effects of amphetamines, carbamazepine, cyclosporine, phenytoin, and quinidine sulphate with concurrent use of carbonic anhydrase inhibitors

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12
Q

furosemide (Lasix®)

  1. Class?
  2. Systems it affects
  3. Useful in the treatment of?
  4. CC effect
A

Loop diuretics

Possess kidney, cardiovascular, and metabolic effects

Useful in treatment of edema

Has diuretic action even when CC is less than 25 mL/min (works even if kidney function is diminished)

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13
Q

Loop Diuretics:

3 Mechanism of Actions

A

Act directly on the ascending limb of the loop of Henle to block CHLORIDE and SODIUM resorption

Increase kidney prostaglandins, resulting in the dilation of blood vessels and reduced kidney, pulmonary, and systemic vascular resistance

Reduces preload and central venous pressure (filling PRESSURE of the ventricles)

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14
Q

Loop Diuretics: Drug Effects

  1. ONSET, DURATION
  2. Potent ____ and subsequent ____ loss
  3. Decreased fluid volume causes a reduction in? (5)
  4. What electrolytes is decreased by furosemide? (3)
A

Rapid onset; last at least 2 hours

Potent diuresis and subsequent loss of fluid

Decreased fluid volume leads to a decreased return of blood to heart, and causes a reduction in:

Blood pressure
Pulmonary vascular resistance
Systemic vascular resistance
Central venous pressure
Left ventricular end-diastolic pressure

Potassium and sodium depletion

Small calcium loss

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15
Q

Loop Diuretics: Indications

A

EDEMA associated with heart failure and liver or kidney disease

HTN (to control)

Kidney excretion of calcium in patients with HYPERCALCEMIA (to increase excretion)

(HF) Heart failure resulting from diastolic dysfunction

Liver cirrhosis

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16
Q

Loop Diuretics: Adverse Effects

A

Central nervous system: Dizziness, headache, tinnitus, blurred vision

Gastrointestinal: Nausea, vomiting, diarrhea

Hematological: Agranulocytosis, neutropenia, thrombocytopenia

Metabolic: Hypokalemia (take K supplements), hyperglycemia, hyperuricemia

Treatment of overdose- fluid and electrolyte replacement

Contraindication: sulfa, anuria, hypovolemia, electrolyte depletion

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17
Q

Loop Diuretics: Interactions

A

Neurotoxic

Nephrotoxic

Increase serum levels of uric acid, glucose, alanine aminotransferase, and aspartate aminotransferase.

thiazide (metolazone): sequential nephron blockade

(NSAIDs) may decrease the reduction of vascular resistance.

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18
Q

Loop Diuretics: Furosemide (Lasix)

  1. Used in conditions such as (5)
A

Most commonly used loop diuretic

Uses:

pulmonary edema and the edema associated with heart failure

liver disease

nephrotic syndrome

ascites

hypertension

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19
Q

mannitol (Osmitrol®)

  1. Class
  2. Works in which part of the nephron?
A

Osmotic Diuretics

Most used osmotic diuretic

Entire nephron, major site of action is proximal tubule and descending limb

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20
Q

Osmotic Diuretics: Mechanism of Action

A

Works along entire nephron but mostly in the proximal tubule and descending loop of Henle

Nonabsorbable, producing an osmotic effect (increases osmotic pressure in GF, pulls fluid into renal tubules)

Pull water into the renal tubules from the surrounding tissues

Inhibit tubular resorption of water and solutes, thus producing rapid diuresis

Reduces cellular edema and increases urine production (not for P. edema because it does not promote sufficient NA excretion)

21
Q

Osmotic Diuretics: Drug Effects (3)

A

Increase GFR and renal plasma flow; help to prevent kidney damage during acute kidney injury

Reduce intracranial pressure or cerebral edema associated with head trauma

Reduce excessive intraocular pressure

22
Q

Osmotic Diuretics: Indications

A

Treatment of:

  1. early, oliguric phase of acute kidney injury
  2. cerebral edema

Reduce intracranial pressure

Used as a genitourinary IRRIGANT in the preparation for transurethral surgical procedures

Promote excretion of toxic substances

23
Q

Osmotic Diuretics: Adverse Effects

A

Convulsions
Thrombophlebitis
Pulmonary congestion
Other: headaches, chest pains, tachycardia, blurred vision, chills, and fever

24
Q

Mannitol (Osmitrol)

  1. Class
  2. Form
  3. Storing instructions and why?
  4. What is needed in its preparation?
A

Osmotic diuretics

IV only

May crystallize when exposed to low temperatures. Therefore, vials are often stored in a warmer.

Use of a filter is required.

25
spironolactone (Aldactone®) 1. Class 2. Also called?
Potassium-Sparing Diuretics Aldosterone-inhibiting diuretics (competes with aldosterone) Used in children HF
26
Potassium-Sparing Diuretics: Mechanism of Action
Work in collecting ducts and distal convoluted tubules Interfere with sodium–potassium exchange Competitively bind to aldosterone receptors Block resorption of sodium and water usually induced by aldosterone secretion
27
Potassium-Sparing Diuretics: Drug Effects
Relatively WEAK compared with the thiazide and loop diuretics Competitively BLOCK aldosterone receptors and INHIBIT their action Promote the EXCRETION of sodium and water
28
Potassium-Sparing Diuretics: Indication of spironolactone and triamterene Indication of amiloride
Hyperaldosteronism Hypertension Reversing potassium loss caused by potassium-wasting diuretics Certain cases of heart failure: prevention of remodelling amiloride- smiliar to spironolactone and triamterene but less effective long term
29
Potassium-Sparing Diuretics: Adverse Effects
Central nervous system: Dizziness, headache Gastrointestinal: Cramps, nausea, vomiting, diarrhea Other: Urinary frequency, weakness, hyperkalemia
30
spironolactone (Aldactone®) ADVERSE EFFECTS
Gynecomastia Amenorrhea Irregular menses Postmenopausal bleeding Treats ascites in high doses (liver cirrhosis) Monitor K- hyoerkalemia is common
31
Potassium-Sparing Diuretics: Interactions
Lithium Angiotensin-converting enzyme inhibitors Potassium supplements NSAIDs Contraindication: hyperkalemia (K greater than 5.5)
32
hydrochlorothiazide (Urozide®)
Thiazide diuretics Ceiling effect Used in pregnancy
33
Thiazide and Thiazide-Like Diuretics: Mechanism of Action
Inhibit tubular resorption of sodium, chloride, and potassium ions Action primarily in the distal convoluted tubule Result in osmotic water loss Dilate the arterioles by direct relaxation, which reduces PVR Decrease preload and afterload
34
Thiazides should not be used if creatinine clearance is _____________________ (normal is 125 mL/min).
is less than 30 to 50 mL/min (normal is 125 mL/min) As idney function decreases, efficacy of thiazides diminishes DRUG: Metolazone remains effective to a creatinine clearance of 10 mL/min.
35
Thiazide and Thiazide-Like Diuretics: Indications
Hypertension (one of the most prescribed group of drugs for this) Edematous states Idiopathic hypercalciuria Diabetes insipidus Heart failure caused by diastolic dysfunction
36
Thiazide and Thiazide-Like Diuretics: Adverse Effects
Central nervous: Dizziness, headache, blurred vision Gastrointestinal: Anorexia, nausea, vomiting, diarrhea Genitourinary: Erectile dysfunction Hematological: Jaundice, leukopenia, agranulocytosis Integumentary: Urticaria, photosensitivity Metabolic: Hypokalemia, glycosuria, hyperglycemia, hyperuricemia, hypochloremic alkalosis
37
Nursing Implications
Assess baseline fluid volume status, intake and output, serum electrolyte values, weight, and vital signs (especially postural blood pressure). Assess for disorders that may contraindicate or necessitate cautious use of these drugs. Instruct patients to take the medication in the MORNING if possible to avoid interference with sleep patterns. Monitor serum POTASSIUM levels during therapy. Teach patients to maintain proper nutritional and fluid volume status. Teach patients to eat more potassium-rich foods when taking any diuretics but the potassium-sparing drugs. Foods high in potassium include bananas, oranges, dates, apricots, raisins, broccoli, green beans, potatoes, tomatoes, meats, fish, wheat bread, and legumes. Patients taking diuretics along with digoxin should be taught to watch for digoxin toxicity. Teach patients to change positions slowly and to rise slowly after sitting or lying, to prevent dizziness and fainting related to orthostatic hypotension. Encourage patients to keep a log of their daily weight. Instruct patients to notify their primary care provider immediately if they experience rapid heart rates or syncope (reflects hypotension or fluid loss). Excessive consumption of LICORICE can lead to additive hypokalemia in patients taking thiazides.
38
Signs and symptoms of hypokalemia includes: (6)
anorexia, nausea, lethargy, muscle weakness, mental confusion, and hypotension.
39
Monitor for adverse effects such as when taking diuretics:
Metabolic alkalosis, drowsiness, lethargy, hypokalemia, tachycardia, hypotension, leg cramps, restlessness, decreased mental alertness
40
Monitor for _______ with potassium-sparing diuretics.
hyperkalemia
41
Monitor for therapeutic effects:
Reduction of edema Reduction of fluid volume overload Improvement in manifestations of heart failure Reduction of hypertension Return to normal intraocular pressures
42
Patients with diabetes mellitus who are taking _____ or ____ diuretics should be told to monitor blood glucose and watch for elevated levels.
thiazide or loop
43
Diuretics
BP: arteriolar dilation, decreases PVR reduce ECF, plasma volume, and CO, decreasing BP diuretics exert their effects on nephrons GFR- how well the kidneys are functioning as filters -GFR below 60 for 3 months & GFR above 60 with kidney damage (high albumin levels in urine >chronic kidney disease 60-70%- promical tubule 20-25% - ascending loop of henle 5-10%-distal tubule (aldosterone selectively filters sodium in exchange to K and H ions) Collecting duct: where ADH acts to increase absorption of water back into the bloodstream, prevents diuresis) Potency-LOOP, osmotic, thiazide like, thiazide, K sparring -the more water and sodium they stop from resorption, the greater the potency Drug interactions with Sulfonamidse- CAIs (acetazolamide, furosemide, thiazide)
44
Normal K levels
3.5 to 5
45
Loop diuretics: possible interaction Lab s to monito when taking loop and thiazide diuretics? 3. Pt taking K sparring diuretic, what is a concern? 4. Teaching for a pt taking spironolactone? 5. PT with diabetes has a new order for thiazide diuretic 6. Loop diuretic 7. Effects of loop diuretic and aminoglycosides
1. NSAIDS 2. Decrease K levels 3. Serum K level of 5.8 4. avoid foods high in K 5. Monitor BG because thiazide diuretic may cause the levels to increase 6. Take the diuretic same time each am, position changes slowly due to dizziness, call doctor if you have muscle weakness/ increased dizziness 7. Ototoxcity
46
Aldosterone
Aldosterone's primary function is to act on the late distal tubule and collecting duct of nephrons in the kidney, favoring sodium and water reabsorption and potassium excretion while also contributing to acid-base balance. Aldosterone is a mineralocorticoid hormone primarily responsible for the renal regulation of sodium balance. Aldosterone binds mineralocorticoid receptors (MR) stimulating sodium reabsorption and potassium excretion by the renal tubules.
47
ADH
Antidiuretic hormone (ADH) is a chemical produced in the brain that causes the kidneys to release less water, decreasing the amount of urine produced.
48
ADH
Antidiuretic hormone (ADH) is a chemical produced in the brain that causes the kidneys to release less water, decreasing the amount of urine produced.

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