Diuretic - e
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Transcript Diuretic - e
Vilasinee Hirunpanich
B.Pharm(Hon), M.Sc In Pharm (Pharmacology)
Outline of diuretic drugs
Basic knowledge in anatomy and
physiology
Classification of diuretics
Classification of Diuretics
Loop Diuretics
Thiazides Diuretics
K+-sparing diuretics
Osmotic Diuretics
Carbonic anhydrase inhibitors
1. Loop diuretics
(high ceiling diuretics)
block Na+-K+-2Cl- cotransport in the thick ascending
limb of the loop of Henle
high efficacy: 25% of filtrated solute is reabsorbed
Structure of loop diuretics
Mechanism of action of Loop of Henle
pharmacokinetic
Rapidly absorbed
Eliminate by renal secretion
Torsemide (1h) is more rapidly than
furosemide (Lasix) (2-3 h)
Duration 2-3 h (furosemide), 3-4 h(torsemide)
Adverse effects
1. Fluid and electrolytes imbalance
Hyponatremia, Hypokalemia and hypomagnesia
2. H+ loss
metabolic alkalosis
3. Ototoxicity
ethacrynic most often
Adverse effects (cont)
4. Hyperuricemia
5. Hyperglycemia
6. Hypersensitivity to sulfonamide
skin rash
7. Others: dehydration
Drug interaction
Ototoxic drugs; aminoglycoside
digitalis glycoside
NSAIDs
probenecid
Litium
anticoagulant
Clinical indications
1. Hypertension and CHF
2. Acute pulmonary edema
3. Other edematous conditions
3. Mild hyperkalemia (simultaneous NaCl and water)
4. I-, Br- intoxication
2.Thiazide Diuretics
Thiazide diuretics
Sulfonamide and benzothiadiazide (thiazide)
derivatives
– Hydrochlorothiazide (HCTZ), indapamide,
chlorthalidone, metolazone
Mechanism of action of thiazide diuretics
Mechanism of actions
Increase Na+, Cl-, K+, Mg2+ in urine….water
retention
Some drug has vasodilator effect such as
indapamide (Natrilix )
Pharmacokinetic
Chlorothiazide is less lipid soluble and
must given in large dose
Indapamide is excreted primarily by the
billiary system
Adverse effects
1.Fluid and electrolytes imbalance
Hypokalemia Hyponatremia Hypercalcemia
2. hyperglycemia due to
impaired pancreatic release of insulin
3.hyperlipidemia
4.allergic reaction
5. Other: weakness, fatigability
Drug interaction
Decrease the effect of
Increase
the
effect
of
anticoagulant
digitalis glycoside
uricosuric agent
lithium
sulfonylurea
insulin
Decrease the effect of thiazide
NSAIDs
bile acid sequestering
probencid
Clinical indications
Hypertension, CHF
hepatic cirrhosis
nephrolithiasis due to idiopathic hypercalcinuria
nephrogenic diabetes insipidus
Br- intoxicity
+
K -sparing
3.
diuretics
+
K
sparing diuretics
1. Aldosterone antagonists
2. Inhibitor of renal epithelium Na+
channel
Aldosterone antagonist
Structure similar to aldosterone hormone
Ex.
spironolactone (synthesis steriod),
eplerenone (spironolactone analog)
spironolactone
specific antagonist
prevent protein synthesis that required for Na+ and K+
transport
increase Na+ excretion and preserve of K+
Potentcy is low and depend on aldosterone level
pharmacokinetic
Spironolactone
Onset and duration of action are determined by the
kinetic of aldosterone response in target tissue.
Slow onset (48 hr)
Canrenone is the active metabolized which has very
long t12.than parent drug.
Adverse effects
hyperkalemia…..life threatening
Endocrine effects
-gynecomastia
-hirsutism
-deepening voice
- decrease libido
contraindication
Pts using salicylate
because inhibiting
canrenone
K+ administration
Clinical use
coadministration with thiazide or
loop diuretic for edema (additive
effect)
hyperaldosteronism
2. Inhibitor of renal epithelium Na+ channel
Triamterene
amiloride
Mechanism of action of K+-sparing diuretic
late distal tubules and
collecting ducts
block Na+ channel in the
luminal membrane
increase NaCl excretion
and decrease K+
excretion
Adverse effect
anemia: triamterene, folic antagonist
kidney stone (triamterene is poorly soluble)
ARF (acute renal failure)
(combination of triamterene and indomethacin has
been reported )
hyperkalemia
life-threatening:
contraindication
Renal failure
other K+ sparing diuretic
ACEI
K+ supplement
NSIADs
Clinical Use
Co administration with other diuretic
(additive effect)
+
prevent depletion of intracellular K
store
Osmotic diuretics
Properties
1. Freely filtered at the glomerulus
2. No reabsorption at the renal tubule
3. No pharmacological effects
Glycerine, Isosorbide, Mannitol, Urea
site of action: Proximal tubule and descending
limb of Henle’s loop
Structure of osmotic diuretics
Mechanism of action
Limit water reabsorption
act as increase urine volume.
increase renal blood flow
Pharmacokinetic
Poorly absorbed so they must be given
parenterally
Mannitol is excreted by glomerular filtration
within 30-60 min
Adverse effects
1. Extracellular volume expansion
Rapidly distributed in the extracellular
compartment and extract water from the
intracellular compartment
2. Dehydration
3. Nausea, vomiting, headache
Clinical Indications
1. To increase urine volume
2. Reduction of intracranial and intraocular pressure
extract water from the eye and brain
Glycerine: control intraocular pressure, pre/post operative
ocular surgery
Mannitol, urea: reduce cerebral edema before/after neurosurgery
5. Carbonic anhydrase inhibitors
Inhibit carbonic anhydrase enzyme at proximal
tubule
SO2NH2 (sulfonamide) group is essential for
activity.
Acetazolamide (Diamox), dichlorophenamide,
ethoxalamide, methazolamide
Structure of carbonic anhydrase inhibitors
Mechanism of action of carbonic
anhydrase inhibitors
1. increase the excretion of HCO3(Urine alkalinization, pH 8)
Increase Na+, K+, secretion
2. Metabolic acidosis
3. eye; decrease formation of aqueous humor
4. Paresthesia, Drowsiness, Somnolence
Pharmacokinetic
Well absorbed after oral administration
The effect of increased of HCO3- is apparent
within 30 min.
Maximal effect within 2 h
Persist for 12 h after single dose
Excrete by tubular secretion
Adverse effects
1. Hypersensitivity
sulfonamide derivative (fever, rashes, bone marrow
suppression)
2. Renal stone
Ca2+ salt are relatively insoluble at alkaline pH.
3. Metabolic acidosis and urine alkalinization
4. Renal potassium wasting
5. Others: drowsiness, paresthesia
Clinical indications
1. Glaucoma (decrease intraocular pressure)
Dorzolamide, brinzolamide (topically use)
2. Urinary alkalinization
increase the secretion of uric acid, weak acid
drugs(aspirin)
3. Metabolic acidosis
4. Acute mountain sickness (24 h before ascent)
Diuretic combination
Loop diuretic& thiazide (different position)
K+sparing diuretic& loop diuretic or thiazide
(decrease ADR)
Moduretic (amiloride + HCTZ)
Dyazide (triamterene+HCTZ)