Chapter 28 Diuretic Drugs

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Nursing implications:

Monitor hyperkalemia with potassium-sparing diuretic

Subtopic

Report rapid heart rate or syncope

Licorice could lead to hypokalemia if taken with thiazide

Change position slowly

Eat potassium-rich food

Report nausea, vomiting, diarrhea

Keep a log of daily weight

Take diuretics in the morning

Diabetic patients taking thiazide and loop diuretics should monitor blood glucose level

Monitor digitalis toxicity when taking diuretics

Monitor serum potassium levels

Chapter 28 Diuretic Drugs

Thiazide and thiazide-like diuretics

* Thiazide should not be used if creatine is <30-50 mL/min * Metolazone remains effective even if creatine is 10 mL/min

Interactions: Anti-diabetic drugs-reduced therapeutic hypoglycemic effect Corticosteroids-hypokalemia Digoxin-digoxin toxicity Lithium-lithium toxicity NSAIDs-decreased diuretic activity

Adverse effects: Dizziness Headache Blurred vision Anorexia Nausea Vomiting Diarrhea Impotence Jaundice Leukopenia Agranulocytosis Urticaria Photosensitivity Hypokalemia Hyperglycemia Hyperuricemia Hypochloremic alkalosis

• Hypertension • Edematous states • Idiopathic hypercalciuria • Diabetes insipidus • HF caused by diastolic dysfunction • Adjunct drugs in treatment of edema related to HF, hepatic cirrhosis, or corticosteroid or estrogen therapy

Inhibit tubular resorption of sodium, chloride, and potassium ions

Chlorthalidone, chlorothiazide, hydrochlorothiazide, indapamide, metolazone

Potassium-sparing diuretics

*Amiloride is less effective in the long term

Interactions: Lithium-lithium toxicity Angiotensin-converting enzyme inhibitors-hyperkalemia Potassium supplements-hyperkalemia NSAIDs-decrease diuretic effect

Adverse effects: Dizziness Headache GI Cramps Nausea, vomiting, diarrhea Urinary frequency Weakness Hyperkalemia

Spironolactone can also induce: Gynecomastia Amenorrhea Irregular menses Postmenopausal bleeding

• Hyper-aldosteronism • Hypertension • Reversing potassium loss caused by potassium-losing drugs • Certain cases of HF: prevention of remodeling

Competitively bind to aldosterone receptors and block resorption of sodium and water usually induced by aldosterone

Amiloride, spironolactone, triamterene

Osmotic diuretics

* Mannitol can only be administered through IV and must use a filter since it may crystallize when exposed to low temperatures.

Adverse effects: Convulsions Thrombophlebitis Pulmonary congestion

• Treatment of patients in the early, oliguric phase of acute renal failure (ARF) • To promote excretion of toxic substances • To reduce intracranial pressure • Treatment of cerebral edema

Non-absorbable, producing an osmotic effect and pull water into the renal tubules from the surrounding tissues.

Mannitol

Loop diuretics

Interactions: • Neurotoxic • Nephrotoxic • Increase serum levels of uric acid, glucose, alanine aminotransferase, and aspartate aminotransferase.

Adverse effects: Dizziness Headache Nausea Vomiting Stevens-Johnson syndrome (torsemide) Agranulocytosis Neutropenia Thrombocytopenia Hypokalemia Hyperglycemia Hyperuricemia Photosensitivity

• Edema associated with HF or hepatic or renal disease • To control hypertension • To increase renal excretion of calcium in patients with • Hypercalcemia • In cases of HF resulting from diastolic dysfunction

Act directly on the ascending limb of the 
loop of Henle to inhibit chloride and sodium resorption. Increase renal prostaglandins, resulting in the dilation of blood vessels and reduced peripheral vascular resistance.

Bumetanide, ethacrynic acid, furosemide, torsemide

Carbonic anhydrase inhibitors

Interactions: • Because CAIs can cause hypokalemia, an increase in digoxin toxicity may occur when they are combined with digoxin. • Use with corticosteroids may also cause hypokalemia. • Increased effects of amphetamines, carbamazepine, cyclosporine, phenytoin, and quinidine with concurrent use of CAIs

Adverse effects: Acidosis Hypokalemia Drowsiness Anorexia Paresthesias Hematuria Urticaria Photosensitivity Melena (blood in the stool)

Contraindicative: Known drug allergy Hyponatremia Hypokalemia Severe renal or hepatic dysfunction Adrenal gland insufficiency Cirrhosis

• Long term management of open angle glaucoma, • Edema, • High-altitude sickness, • Used with miotics to lower intra-ocular pressure before ocular surgery.

CAIs block the action of carbonic anhydrase, thus preventing the exchange of H+ ions with sodium and water.

Acetazolamide