pharm: 10-12 Diuretics Flashcards
Carbonic Anhydrase Inhibitors
- Indications (5)*
- B: Main Example*
- C: What renal Secretory pump does they use?*
โCarbonic Anhyrase Inhibitors are Mega HUGE like Mountainsโ
- To reduce intraocular pressure in Glaucoma.
- โMountain Altitude sicknessโ (treats by DEC serum pHโ>DEC HgB affinity for O2โ> [INC Tissue O2 Delivery])
- [Urine pH] INCREASE in cystinuria
- HypOkalemic periodic paralysis (will require Dietary K+)
- Epilepsy adjunct tx
B: Acetazolamide
C: [Organic Acid (MATE) Transporter]
Osmotic Diuretics
Indications (3)
- Tx or Prevention for Acute Renal Failure
- DEC intra-cranial and intra-ocular pressure
- Enhance Urinary Excretion of Chemical Toxins
Loop Diuretics
- Indications (6)*
- B: Effect on Venous and Renal Vasculature*
- C: How long post administration does it take to act?*
CANCHA
- Acute Pulmonary Edema.
- HTN
- (CHF)โin the presence of renal insufficiency or for immediate effect.
- [ACA - ARF, CRF, Ascites],
- Nephrotic syndrome
- HyperCalcemia
B: Venous and Renal vasoDILATIONโ> LATER DEVELOPING DEC TPR
C: 20 min. to act but absorption rate is DEC in CHF pts
Thiazides
- Indications (6)*
- B: Site of Action (2)*
- C: Condition that prevents* Thiazides from being used? Whatโs the [Thiazide Family] Exception?
โThiazide drink is a Happy CIDERโ
- Hypertension.
- Edema 2ยบ to CHF,
- Cirrhosis,
- Renal disease.
- [Idiopathic Hypercalcuric Renal Calculi]
- [Diabetes Insipidus-nephrogenic] (prevent further urine dilution from taking place in the DCT).
B: [Early DCT] and [cortical thick aLOH]
C: [Severe Renal Insufficiency] โ> use [Metolazone Quinazoline] since it is the strongest of [Thiazide Family]
K+ Sparing Diuretics
- A: 4 Main Drugs*
- B: Indications (4)*
- C: Which 2* K+ Sparing Diuretics can treat Hyperaldosteronism?
D:
*_____ and _____ have side effects = Hyperkalemia/ Gynecomastia/ [Testicular Atrophy]
- _____ has sie effects= megaloblastic anemia in liver failure pts
- ______ has side effects= cause Glucose Intolerance in Diabetics
E: MAJOR SIDE EFFECT FOR ALL
A: SEAT - Spironolactone/ Eplerenone/ Amiloride / Triamterene
B:
- [S**econdary HyperAldosteronism 2ยบ to Cirrhosis or CHF]
- [Connโs Primary hyperaldosteronism syndrome]
- Prevents hypOkalemic effects of other diuretics.
- HTN adjunct tx
C: SPIRONOLACTONE AND EPLERENONE
D:
- Spironolactone/Eplerenone SE = Hyperkalemia/ Gynecomastia/ [Testicular Atrophy]
- Triamterene can cause megaloblastic anemia in liver failure pts
- Amiloride can cause Glucose Intolerance in Diabetics
E: METABOLIC ACIDOSIS
ADH Blockers
- Indications (3)*
- Main Examples (3)*
- SIADH
- hypOnatremia (Euvolemic or Hypervolemic)
- CHF
B: Tolvaptan / Doxycycline / Lithium
Carbonic Anhydrase Inhibitors
- Side Effects (4)*
- B: Why are they contraindicated in Cirrhosis pts?*
โ CAMP is a Side Effect of Carbonic Anhydrase Inhibitors โ
- Metabolic acidosis 2ยบ to HCO3-
- Acute hypokalemia
- [CNS depression + Drowsiness and fatigue],
- Paresthesia
B: increased urine pH DEC [NH3 secretion] โ> [INC serum NH3]โโ> hyperammonemia in Cirrhosis pts โ> Encephalopathies
Loop Diuretics
Side Effects (8)
โGoing in a Loop? DUNK and MOVMโ
- hypOKalemia (may be linked to hyperglycemia)
- hypOMagnesemia;
- hypONatremia;
- Volume Contraction in serum***
- HyperUricemia โ> Gout
- Metabolic alkalosis
- Ototoxicity (reversible)
- Diarrhea (when using ethacrynic acid)
Thiazide
Side Effects ( 11 )
โWanna know Thiazide Side Effects? Get a CAULKiiNG VoiceMail โ
- hypOKalemia;
- hypONatremia;
- hypOVolemia;
- HyperUricemia due to INC urate ReAbsorption*
- HyperCalcemia due to INC Ca2+ ReAbsorption
- Metabolic alkalosis
- [HyperGlycemia 2ยบ to DEC in Insulin Secretion]
- HyperLipidemia (HIGH doseโ> INC LDL and TAG)
- Allergic rxn (fever, rash, purpura, anaphylaxis);
- Interstitial nephritis and Impotence
**Thiazides should be used in low doses**
The vaptan family (Tolvaptan / Conivaptan / Mozavaptan] are all ______ blockers in the Kidney.
Name their common Side Effects (5)
B: Which vaptan is effective orally
C: Which vaptan is a combined [V1a and V2 Receptor Blocker] which allows it to also treat _________ by ________
vaptan family (Tolvaptan / Conivaptan / Mozavaptan] are all ADH blockers in the Kidney.
SE:
- Hypernatremia
- Thirst
- Dry Mouth
- hypOtension
- Dizziness
B: Tolvaptan
C: Conivaptan (IV ONLY) also treats [Euvolemic hypOnatremia] by vasoconstricting arterials + Diuresis
What Potential Interactions do the Rx below pose to the pt?
[ACEk2 Inhibitors]
+
[K+ Sparing Diuretics - SEAT]
B: How do you circumvent this
INC Hyperkalemia โ> Cardiac Arrhythmias
B: Monitor Serum K+
What Potential Interactions do the Rx below pose to the pt? (2)
Aminoglycosides
+
Loop Diuretics
B: How do you circumvent this (2)
- Ototoxicity
- Nephrotoxicity
* B: Monitor hearing and Serum creatinine*
What Potential Interactions do the Rx below pose to the pt? (2)
Anticoagulants
+
[Loop Diuretics] vs. Thiazides
increased anti-coagulant activity with Loop diuretics;
vs.
decreased anti-coagulant activity with thiazide diuretics.
What Potential Interactions do the Rx below pose to the pt? (4)
Beta Blockers
+
[Loop Diuretics AND Thiazides]
INC PLUG in the plasma!
Propranolol
Lipid (HyperLipidemia)
Uric acid (Hyperuricemia)
Glucose (Hyperglycemia)
What Potential Interactions do the Rx below pose to the pt?
Thiazide
+
[Carbamazepine or Chlorpropamide]
hypOnatremia (monitor Na+!)
What Potential Interactions do the Rx below pose to the pt?
Digoxin
+
[Loop Diuretics AND Thiazide]
B: How do you circumvent this
hypOkalemia โ> INC Digoxin Toxicity
B: Monitor K+ and Cardiac Function
What Potential Interactions do the Rx below pose to the pt? (3)
NSAIDs
+
[Loop / Thiazide / K+ Sparing DIURETICS]
๔ฐ 1. reduced diuretic effect,
- increased risk of salicylate toxicity with high doses of salicylates (thiazide & loop d.).
๔ฐ - increased risk of hyperkalemia with K+ sparing diuretics
What Potential Interactions do the Rx below pose to the pt?
Quinidine
+
[Loop Diuretics or Thiazide]
Polymorphic VTach (Torsade De Pointes)
What Potential Interactions do the Rx below pose to the pt?
Sulfonylureas
+
Loop Diuretics
Hyperglycemia
What Potential Interactions do the Rx below pose to the pt?
Steroids
+
[Loop Diuretics or Thiazide]
hypOkalemia
(monitor serum K+)
Renal Papillae
[Renal Papillae] form [Funnel-shaped ______], which then converge to form a ________
A Conjoined Apex of all the [Medullary pyramid] ducts
[Renal Papillae] form [Funnel-shaped Calyces], which then converge to form a Renal Pelvis
A: Most diuretics are tightly ______ bound and undergo ______ glomerular filtration.
They reach renal tubule lumen via ______ across the ______ cell (______ or ______ secretory pathway)
A2: Which Diuretic works via Glomerular filtration?
B: 2 Drugs that inhibit acidic drugs secretory pump
C: Which Drug competes with Basic drugs secretory pump
A: Most diuretics are tightly protein bound and undergo little filtration. They reach renal tubule lumen via secretion across the PCT cell (organic acid or base secretory pathway)
A2: Mannitol
B: [probenecid and NSAIDs] compete with acidic
C: cimetidine
Osmotic Diuretics (Mannitol)
A: Route of Administration
B: Parts of the Kidney it acts (3)
C: Contraindications (3)
C2: Rationale behind Contraindications
A: IV ONLY and initially causes [Intravascular volume expansion].
B: PCT / [thin descending LOH] / [Collecting Duct w/ADH around]
C:
- CHF
- Chronic Renal Failure
- Acute Pulmonary Edema
C2: In pts with DEC GFR, [Osmotic Diuretics] distribute into the [Extracell Fluid] and then pull WATER AND Na+ Out of cells โ> Worsening condition
Which Loop Diuretic has a ________ than Furosemide
A: GREATER POTENCY
B: Longer Half-Life and [Duration of Action]
C: Greater TOXICITY (nephro/ototoxic and is last resort)
D: Better PO absorption
A: Bumetanide
B: Torsemide
C: Ethacrynic Acid
D: Torsemide
Contraindications for [K+ Sparing Diuretics - SEAT] (9)
*These conditions can cause HYPERkalemia*
โ Have a SEAT on our Hot TM BRANDSโ
- DM
- Multiple Myeloma
- [Tubulointerstitial Renal Dz]
- Renal Insufficiency
- [ACEk2 inhibitors and ARBs]
- Supplemental K+
- NSAIDs
- Heparin
- Beta Blockers
Differences between Spironolactone and Eplerenone (2)
- Eplerenone is considerably more expensive
- Eplerenone does not inhibit testosterone binding and therefore it does not induce gynecomastia or other related anti-androgenic side effects
How is Diabetic Nephropathy and Diuretics related?
Diabetic nephropathyโassociated with HYPERkalemiaโmay be treated with [loop diuretics or thiazides]
A: What is the most common electrolyte disorder in hospitalized patients?
B: What are the 3 Types
B2: Which types can NOT be treated with [saline infusion] (2), and what is the alternative tx (2)
B3: Which type is associated with SIADH
C: What specifically was Mozavaptan just approved for?
A: hypOnatremia, (less than 136 mEq/L)
B: hypOvelimic vs. Euvolemic vs. HYPERvolemic
B2: Euvolemic and HYPERvolemic] can NOT be treated w/saline infusion โ> use [Tolvaptan or Conivaptan]
B3: [Euvolemic hypOnatremia] <โSIADH
C: hyponatremia caused by SIADH due to ADH producing tumors
Current Recommendations for HTN tx with Diuretics
A: For uncomplicated HTN
B: Pts with DM and Chronic Renal Dz
C: Pt whose BP is more than [20 over Systolic goal] or [10 over diastolic goal]
A: a thiazide diuretic should be used in drug either alone or combined with drugs from other classes.
B: 2 or more antihypertensive medications will be required to achieve goal BP (140/90 mm Hg, or 130/80 mm Hg)
C: initiation of therapy using two agents, one of which is a thiazide diuretic
Causes of Diuretic Resistance or Edema Refractory (4)
๔ฐ 1. NSAID co-administration (block prostaglandin-induced increase in RBF / [INC expression of Na+/K+/2Cl- in TAL], compete for organic acid transporter in PCT).
๔ฐ 2. (CHF) or renal failure DEC RBFโ> decreases delivery of diuretics to tubule / build-up of organic acids competes for secretory transport into tubule.
๔ฐ 3. Nephrotic syndrome (protein in tubule binds to diuretic drugs and limits their actions).
๔ฐ 4. [Hepatic cirrhosis / CHF / renal failure] (decreased GFR results in increased PCT absorption of Na+
A: Which Blood Pressure medication is best for Pts with [Metabolic Syndrome X]?
B: Criteria for [Metabolic Syndrome X] (4)
DIURETICS
B: [Metabolic Syndrome X - DIVe] is when pt has
1. Dyslipidemia [TG over 150] or [HDL under 40]
- Insulin resistance [Fasting Glucose OVER 100]
- Visceral Obesity [Men Waist over 40] or [Women Waist over 35]
- HYP(e)RTENSION [BP over 135/80]
