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pre reg afsha CV > Loop diuretics > Flashcards

Loop diuretics Flashcards

1
Q

Which conditions are loop diuretics prescribed for

A

Used in pulmonary oedema due to LV failure and for management of oedema in patients with chronic HF

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2
Q

MoA

A

Loop diuretics inhibit reabsorption from the ascending limb of the loop of Henlé in the renal tubule and are powerful diuretics

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3
Q

Discuss the use of loop diuretics in pulmonary oedema due to LV failure

A
  • IV administration will produce relief of breathlessness
  • It reduces pre-load sooner than would be expected from the time of onset of diuresis (increased/excessive urine production)
  • Decreases preload helps reduce the amount of blood the heart has to pump
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4
Q

What is diuretic resistant oedema

A

Failure to achieve the therapeutically desired reduction in oedema even when a maximal dose of diuretic is employed

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5
Q

How to treat diuretic resistant oedema (except lymphoedema and oedema due to peripheral venous stasis or CCB)

A

Loop diuretic + thiazide or related diuretic (e.g. bendroflumethiazide or metolazone)

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6
Q

Examples of loop diuretics

A

Furosemide
Torasemide
Bumetanide

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7
Q

Using a loop diuretic in antihypertensive patients

A

Loop diuretic can be added to antihypertensive treatment to achieve better control of BP in pt with resistant hypertension or impaired renal function or HF

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8
Q

Which conditions may loop diuretics exacerbate

A

Diabetes
Gout

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9
Q

What is the advantage of using loop diuretics in pt with diabetes over thiazides?

A

Although loop diuretics can exacerbate diabetes, hyperglycaemia is less likely than with thiazides

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10
Q

Using loop diuretics in pt with enlarges prostate

A

Urinary retention may occur, but is less likely if small doses and less potent diuretics are used initially
Manufacturer advises adequate urinary output should be established before initiating treatment

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11
Q

Activity of furosemide and bumetanide

A
  • Similar activity
  • Diuresis is dose related
  • Act within 1h or oral administration
  • Diuresis complete within 6 hours - if necessary, can be given BD without interfering sleep
  • Following IV administration, furosemide has peak effect within 30 mins
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12
Q

Activity of torasemide

A
  • Similar properties to furosemide and bumetanide
  • Indicated for oedema and hypertension
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13
Q

Pt parameters to check before starting loop diuretic

A

Renal function, serum electrolytes, BP

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14
Q

Monitoring requirements after starting treatment

A
  • Recheck renal function, serum electrolytes and BP 1-2 weeks after starting treatment
  • Earlier monitoring (after 5-7 days) may be required in people with:
  • existing CKD stage 3 or higher
  • 60 or over
  • relevant comorbidities e.g. DM, peripheral arterial disease
  • taking diuretic + ACEi/ARB/MRA
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15
Q

Recommended starting dose of bumetanide for people with HF

A

0.5mg in the elderly to 1mg

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16
Q

Recommended starting dose of furosemide in pt with HF

A

20-40mg

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17
Q

Recommended starting dose of torasemide in pt with HF

A

5-10mg

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18
Q

Daily dose of bumetanide in pt with HF

A

1-5mg
Elderly 0.5mg

19
Q

Daily dose of furosemide in pt with HF

A

20-120mg

20
Q

Daily dose of torasemide in pt with HF

A

10-20mg

21
Q

Dose titration

A
  • Start with low dose
  • Titrate dose up or down according to symptoms and signs of fluid overload
  • Use the lowest possible dose to control symptoms
22
Q

Excessive diuresis can cause…

A
  • postural hypotension
  • dehydration
  • AKI
  • electrolyte imbalances
23
Q

What to do if pt shows evidence of symptomatic hypotension, dizziness, light headedness or confusion

A
  • Consider reducing dose of diuretic OR
  • Reducing dose of any concomitant drug known to reduce BP , OR
  • Seeking expert advice
24
Q

When is the dose of loop diuretic normally given?

A
  • Usually once daily in the morning
  • Can be given twice daily (morning & lunchtime) for additional diuresis
  • Pt can be advised to adjust timing of doses to suit their social needs
25
Q

Max initial dose for people with HF and preserved ejection fraction

A

Max initial dose is up to 80mg furosemide

26
Q

You need to provide eduction to the pt/carer regarding… (3 points)

A
  • how to adjust dose according to changes in weight
  • avoiding excessive fluid intake
  • avoiding dehydration (thirst, dizziness, fatigue)
27
Q

What to advice the patient if they develop diarrhoea and vomiting while taking diuretic

A
  • maintain fluid intake and stop diuretic for 1-2 days until they recover
  • stopping treatment for a short time is thought to avoid dehydration, hypotension, and AKI, and should not cause a sudden deterioration in HF
  • if symptoms persist beyond 2 days see a GP and have bloods checked
28
Q

What to do after restoration of dry body weight (removal of most or all pt excess fluid) and subsequent treatment for HF has been introduced

A
  • Review loop diuretic dose and adjust as necessary
  • This will reduce risk of dehydration, AKI and electrolyte disturbances
29
Q

Monitoring after each dose increase

A
  • Renal function, serum electrolytes and BP 1-2 weeks after each dose
  • Earlier monitoring (after 5-7 days) may be required for pt with
  • existing CKD stage 3 or higher
  • 60 or over
  • relevant comorbidities such as DM or peripheral arterial disease
  • combination of diuretic + ACEi, ARB, MRA
30
Q

Monitoring requirements once treatment is stable

A

Renal function + serum electrolytes at least once every 6 months

31
Q

Contraindications for all loop diuretics

A
  • Anuria
  • Comatose and pre comatose states associated with liver cirrhosis
  • Renal failure due to nephrotoxic or hepatotoxic drugs
  • Severe hypokalaemia
  • Severe hyponatraemia
32
Q

Cautions for all loop diuretics

A
  • Can exacerbate diabetes (but hyperglycaemia less likely than with thiazides)
  • Can exacerbate gout
  • Correct hypotension before initiation
  • Correct hypovolaemia before initiation
  • Urinary retention may occur in prostatic hyperplasia
  • Elderly: lower initial doses may be necessary because they are particularly susceptible to SE, and adjust dose according to renal function
33
Q

Prescription potentially inappropriate STOPP criteria for elderly

A
  • as 1st line treatment for hypertension - there is safer, more effective alternatives
  • for treatment of hypertension with concurrent urinary incontiennce - may exacerbate incontinence
  • for dependent ankle oedema without evidence of HF, liver failure, nephrotic syndrome or renal failure: leg elevation/compression hosiery usually more appropriate
34
Q

Potassium loss

A
  • hypokalaemia may occur in loop diuretics
  • this is dangerous in severe CVD and in pt being treated with cardiac glycosides
  • often the use of potassium-sparing diuretics avoids the need to take potassium supplements
  • in hepatic impairment, hypokalaemia caused by diuretics can precipitate encephalopathy
35
Q

Common or very common SE for all loop diuretics

A
  • dizziness
  • electrolyte imbalance
  • fatigue
  • headache
  • metabolic alkalosis
  • muscle spasms
  • nausea
36
Q

State an uncommon side effect of loop diuretics

A

diarrhoea

37
Q

Hepatic impairment

A
  • hypokalaemia induced by loop diuretics may precipitate hepatic encephalopathy and coma - potassium sparing diuretics can be used to prevent this
  • diuretics can increase risk hypomagnesaemia in alcoholic cirrhosis leading to arrhythmias
38
Q

Renal impairment

A
  • high doses or rapid IV administration can cause tinnitus and deafness
  • high doses may occasionally be needed in renal impairment
39
Q

Furosemide - use in pregnancy and BF

A

Preg: do not use to treat gestational hypertension because of maternal hypovolaemia associated with this condition
BF: amount too small to be harmful, may inhibit lactation

40
Q

Furosemide doses in oedema, resistant oedema and resistant hypertension

A

Oedema: initially 40mg OM, then maintenance is 20-40mg daily
Resistant oedema: 80-120mg daily
Resistant hypertension: 40-80mg daily

41
Q

Bumetanide doses in oedema and severe cases of oedema

A

Oedema: adult: 1mg in the morning, then 1mg after 6-8 hours if needed
Oedema: elderly: 500mcg daily
Severe cases of oedema: initially 5mg daily, increased in steps of 5mg every 12-24 hours, adjusted according to response

42
Q

Bumetanide in pregnancy and BF

A

Preg: do not use to treat gestational hypertension because of the maternal hypovolaemia associated with this condition
BF: no info available, may inhibit lactation

43
Q

Torasemide dosage in oedema and hypertension

A

Oedema: 5mg OD, pref in morning, then increased if necessary up to 20mg OD, max 40mg daily
Hypertension: 2.5mg daily, then increased if necessary to 5mg OD

44
Q

Torasemide in pregnancy and BF

A

Preg: avoid
BF: avoid

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