diuretics

Question 1

Specific Goals of Heart Failure Managementwith Pharmacotherapy

Answer 1

1. reduction of congestion
2. modulate neurohormonal activation
3. improve flow

Question 2

reduction of congestion can be accomplished by

Answer 2

fluid otpimization with diuretics is a mjor part of HF therapy

Question 3

modulate neurohormonal activation, resulting in long term stabilization, positive remodeling and increased survival with

Answer 3

RASS antagonists and

B blockers

Question 4

improve blood flow with

Answer 4

vasodilators

This can be difficult and can require mechanical devices or transplantation

Question 5

diuretics are used first as need to

Answer 5

reduce cogestion

Question 6

how do diuretics reverse congestion?

Answer 6

1. Reverse Na+ and fluid retention
2. Relieve volume overload: dyspnea-peripheral edema
3. Lowers preload (LVEDP)

Can be used chronically and acutely

Furosemide most common

Torsemide or bumetanide - more reliable absorption

Question 7

What diuretics are used preferentially and why?

Answer 7

Loop diuretics preferred because of efficacy - can augment with a thiazide diuretic

Question 8

Are diuretics used chronically or acutely?

Answer 8

both!

Question 9

most common diuretic used?

Answer 9

1. Furosemide most common

2. Torsemide or bumetanide - more reliable absorption

Question 10

when are ACEIs started?

Answer 10

1. during or after optimization of diuretic therapy

2. initiated at low doses and titrated to goal

Question 11

ACEIs produce

Answer 11

1. vasodilation
2. decrease aldosterone activation
3. antiremodeling effect

Question 12

ARBs are used in patients

Answer 12

intolerant to ACEIs (most often cough)

Question 13

benefit from ACEI and ARB together?

Answer 13

No apparent benefit

Question 14

aldosterone antagonist are added to therapy for

Answer 14

1. LVEF < 30-35%

2. optimized on ACEI/ARB and β-blocker therapy

Question 15

Aldosterone antagonists function to

Answer 15

1. Blocks aldosterone effect on kidney
2. ACEI / ARB aldosterone block is incomplete
3. Antiremodeling action plus produces additional Na+ loss at the kidney

Question 16

aldosterone antagonists you have to carefully monitor

Answer 16

1. serum K+ (< 5.0)
2. renal function
   (GFR > 30 ml/min) as agents are potassium-sparing

Question 17

what aldosterone antagonist is preferred?

Answer 17

Spironolactone preferred if tolerated - if endocrine side effects (gynecomastia) can use eplerenone

Question 18

diuretic agents

Answer 18

1. Hydrochlorothiazide
2. Furosemide (Lasix®)
3. HCTZ-Triamterene (Dyazide)
4. Spironolactone (Aldactone®)
5. Triamterene (Dyrenium®)
6. Amiloride (Midamor®)
7. Chlorthalidone (Thalitone®)
8. HCTZ-Aldactazide (Aldactazide®)
9. Bumetanide (Bumex®)
10. Torsemide (Demadex®)
11. Ethacrynic acid (Edecrin®)

Question 19

Most diuretics exert effects at

Answer 19

lumenal (urine) surface of renal tubule cells

Question 20

Diuretics can

Interact with

Answer 20

1. membrane transport proteins
2. enzyme
3. hormone receptor
4. osmotic effects preventing water reabsorption

Question 21

Which Diuretics

Interactions with membrane transport proteins

Answer 21

1. thiazides
2. furosemide
3. triamterene

Question 22

Which Diuretics

Interactions with enzymes?

Answer 22

acetazolamide

Question 23

Which Diuretics

Interactions with hormone receptors?

Answer 23

spironolactone

Question 24

which diuretics have osmotic effects preventing water reabsorption?

Answer 24

mannitol

Question 25

diuretics, what is the major EC cation?

Answer 25

Na+

Question 26

for diuretics, movement of Na+ is controlled by

Answer 26

active transport via Na+-K+-ATPase activity at interstitial (blood) surface

Question 27

Diuretics: At kidney, Na+-K+-ATPase produces

Answer 27

gradient necessary for Na+ reabsorption from the urine back into the blood

Question 28

No diuretics act via

Answer 28

inhibition of Na+-K+-ATPase

Question 29

How do diuretics work?

Answer 29

1. Diuretics agents decrease Na+ reabsorption at various sites in the nephron
2. Increased amounts of Na+ (and other ions) enter urine with H2O (passively to maintain osmotic equilibrium)