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OS Renal > Diuretics Pharmacology > Flashcards

Diuretics Pharmacology Flashcards

1
Q

What part of the nephron do CA inhibitors act on?

A

PT

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2
Q

CA inhibitors MOA

A

Inhibition of CA causes bicarbonate excretion to go up. Being alkaline, makes urine basic.

Enhanced Cl- reabsorption that results in acidosis

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3
Q

What are the major clinical uses for CA inhibitors?

A

To alkalinize urine in cysteinuria
To reduce intraocular pressure
Manage seizures
Give prohpx for mountain sickness

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4
Q

What is the one CA inhibitor named?

A

Acetazolamide

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5
Q

What are the side effects of acetazolamide?

A

Metabolic acidosis

K+ loss in urine acutely that goes away

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6
Q

MOA of osmotic diuretics

A

PCT: isoosmotic so not reabsorbed, and it retains water (minor effect)

LOH: wipes out hypertonicity of medulla by increasing medullary blood flow; results in less water reabsorbed in DLH

(Change renal hemodynamics resulting in less water reabsorption in TDLH)

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7
Q

Effects of osmotic diuretics on LOH

A

Extract water from tissues
Decrease blood viscosity
Inc medullary renal flow, reduce tonicity

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8
Q

What is an example of an osmotic diuretic?

A

Mannitol

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9
Q

What are the side effects of mannitol?

A 
Volume overload (bc large dose and osmolarity up)
Contraindicated in cardiac failure
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10
Q

Do osmotic diuretics cause more free water excretion?

A

yes

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11
Q

What are osmotic diuretics still used for?

A

Dialysis disequilibrium
Reduce intracranial pressure
Reduce intraocular pressure

These effects are very immediate

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12
Q

MOA of Loop diuretics

A 
Inhibit Na/K/2Cl symporter in TALH
Causes MD to inc filtration by blocking it from sensing Na (uses NaKCl transporter to)
Up biosynthesis of prostaglandins
Inc total RBF
Maintain GFR
Renin secretion increases
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13
Q

Do loop diuretics affect the urine concentrating ability?

A

Yes, decrease ability to concentrate

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14
Q

How do loop diuretics affect the filtration fraction?

A

Increase by about 5%

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15
Q

What about prostaglandins and loop diuretics

A

More prostaglandins made which increase blood flow to kidneys

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16
Q

How to loop diuretics change the afferent artery?

A

Decrease resistance to inc GFR

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17
Q

How do loop diuretics contribute to renin release?

A

Inhibiting the macula densa
Activating SNS
Stimulating intrarenal bareoreceptors

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18
Q

Loop diuretics increase excretion of which ions?

A 
NaCL
K
H
Ca
Mg
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19
Q

Which kind of diuretic is the most potent NaCL mobilizer and diuresis inducer?

A

Loop diuretics

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20
Q

What are the therapeutic uses for loop diuretics?

A

Edema, inc. cardiac, hepatic, renal, pulmonary
Hypercalcemia
Protect against renal failure (esp post-op)
Wash out toxins

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21
Q

Where does furosemide enter the nephron?

A

Secreted in by proximal tubule

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22
Q

Why does furosemide have a high therapeutic window?

A

In renal disease patients, PCT secretions are reduced so you can give a lot more of drug

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23
Q

Why do you need to make sure that people on loop diuretics stay well hydrated?

A

So they don’t form kidney stones of Ca from increased urinary excretion

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24
Q

What kind of vascular changes does furosemide cause?

A

Venodilation somehow

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25
Q

What are the side effects of furosemide?

A 
Hypokalemia - give supplement
pH disorders esp alkalosis
BUN up
Hyperglycemia
Hyperuricemia
Ototoxicity and sialadentitis
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26
Q

What are some major drug interactions of furosemide?

A

Li+ urinary excretion
Indomethacin - prostaglandin inhibitor
Probenecid - inhibits furosemide secretions
Warfarin - compete for protein binding

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27
Q

What are the three loop diuretics

A

Furosemide
Bumetanide
Torsemide

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28
Q

Which is most potent loop diuretic?

A

Bumetanide

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29
Q

How do loop diuretics cause hypokalemia?

A

Increased distal sodium delivery causes lots of reabsorption in distal CT and CD, making a steep gradient for K+ to be secreted into (-) lumen

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30
Q

Thiazide diuretics MOA

A

Inhibit NaCl reabsorption in Na/K aldosterone-independent segment of distal tubule

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31
Q

Which diuretics are used chronically?

A

Thiazides

32
Q

What ions do thiazide diuretics affect?

A

Increase Mg excretion

Decrease Ca excretion (unlike loops)

33
Q

What are the uses for thiazides?

A 
Edema from CHF, cirrhosis, nephrotic
Hypercalciurea/calcium stones
Reduce blood pressure
Augment antihypertensives
Osteoporosis - dec urine calcium
Nephrogenic DI
34
Q

Why are thiazides used in HT?

A

Unknown how, but they are vasodilators

35
Q

What is the difference between class I and II diuretics?

A

Class I - use when GFR > 50 mL

Class II - use when GFR between 50-30

36
Q

What are the Class I thiazides?

A

Hydrochlorothiazide
Clorthalidone
Quinethazone

37
Q

What are the Class II thiazides?

A

Metolazone

Indapamide

38
Q

What are the aldosterone antagonists?

A

Spironolactone

Eplenerone

39
Q

Are aldosterone antagonists K sparing or wasting?

A

Sparing

40
Q

Spironolactone PK

A

pro-drug extensively metabolized

41
Q

Side effects of spironolactone

A

Hyperkalemia

Gynecomastia, hirsutism, uterine bleeding

42
Q

Clinical uses for aldosterone antagonists

A

Think CHF!

Also cirrhosis

43
Q

Why is eplenerone better than spironolactone?

A

Much more mild side effects

44
Q

What do aldosterone antagonists do to ion levels?

A

Increase Na excretion

Decrease K excretion

45
Q

What are the K-sparing diuretics (class)?

A

Triamterene

Amiloride

46
Q

What are the side effects of K sparing?

A

Hyperkalemia

Megaloblastic anemia in pts with cirrhosis

47
Q

What is MOA of K sparing

A

Inhibit Na reabsorption in late distal tubule

48
Q

Where does ANP act?

A

Induces guanylyl cyclase to make cGMP, which inhibits Na reabsorption

49
Q

What is the ANP drug?

A

Nesiritide

50
Q

Nesiritide MOA for Na excretion

A

Inhibits CNG nonspecific cation channel in CD

Inhibits RAAS

51
Q

Why is nesiritide useful in CHF?

A

Decreases systemic vascular resistance through NO production
Decreases LV filling pressure
Increase cardiac output

52
Q

What is the best combo for hypertension?

A

Diuretics with ACE inhibitors

53
Q

What diuretic would you give to someone with mild to moderate hypertension?

A

Thiazide

54
Q

When would you absolutely need to use a loop diuretic instead of another in terms of GFR?

A

GFR below 30

55
Q

What diuretic would you give to someone with severe hypertension who doesn’t respond to thiazides?

A

Loop diuretics

56
Q

What would you give to someone who has acute pulmonary edema or a hypertensive crisis?

A

Furosdemide

57
Q

What drug class should patients avoid while using loop diuretics?

A

NSAIDs

58
Q

What diuretic would you give to a patient with hyperuricemia?

A

K sparing or aldosterone antagonist

59
Q

What diuretic would you give to a patient with cirrhosis?

A

Spironolactone

60
Q

Are thiazides or K-sparing diuretics more useful for antihypertensives?

A

Equally useful PUNK’D

61
Q

Where are V1 receptors found?

A

Vascular smooth muscle

62
Q

What does AVP do when it binds to V1?

A

PLC cascade that causes vasoconstriction

63
Q

Where are V1 receptors found?

A

Principal cells in collecting ducts

64
Q

What type of cascade is coupled to the V2 receptor?

A

GS GPCR cascade that causes PKA phosphorylation of AQP2, resulting in translocation to apical membrane

65
Q

What are the V1-receptor agonists?

A

vasopressin (discontinued)

terlipressin

66
Q

Why do you use V1 receptor agonists

A

GI and vascular smooth muscle contraction

67
Q

What are the clinical uses for V1 agonists

A

Post-op ileus

Reduce bleeding during acute hemorrhagic gastritis

68
Q

What are the causes of diabetes insipidus

A

Inadequate AVP secretion (central)

Insufficient kidney response to AVP (nephrogenic)

69
Q

How can you distinguish between nephrogenic DI and central DI?

A

Give a V2R agonist (desmopressin) and see if urine osmolarity increases. If it does, they have central. If not, nephrogenic.

70
Q

What is the most common causes of central DI?

A

Head injury, CNS ischemia, tumors, V2R gene mutations

71
Q

How are thiazide diuretics helpful in DI?

A

Cause mild depletion of EC water and Na, activating renal compensation to increase reabsorption in PCT. Reduces volume delivered to distal tubule.

72
Q

What are the three drug classes that can cause SIADH?

A

Psychotropics
Sulfonylureas
Vinca alkyloids

73
Q

How are V2 receptors targeted in SIADH patients

A

Demeclocycline which antagonists V2R

74
Q

What are the selective V2R antagonists?

A

Tolvaptan

Conivaptan

75
Q

What is the black box warning for V2R antagonists?

A

Can only be used in a hospital setting

OS Renal (25 decks)

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