Diuretics Petit Nacario BSN 3 DEFINITION DIURETICS- drugs that increase the excretion of sodium and therefore water

from the kidneys. They are classified according to their: 1. Sites of action 2. Diuretic potency 3. chemical structure FUNCTIONS TO DECREASE: 1. blood volume 2. venous pressure 3. Arterial pressure 4. Pulmonary and peripheral edema 5. Cardiac output CLASSIFICATION 1. Potassium-Sparing Diuretics 2. Potassium-losing Diuretics 1. Thiazide and thiazide-like diuretics 2. Loop diuretics 3. Carbonic Anhydrase 3. Osmotic Diuretics POTASSIUM-SPARING DIURETICS Are mild diuretics that act to spare potassium (k) in exchange for the loss of sodium and water in urine. Preferable if potassium loss could be detrimental to a patients cardiac or neuromuscular condition. Patients should be careful not to become hyperkalemic while taking these drugs. ACTION AND USE Block aldosterone receptors and work in the collecting ducts and distal convoluted tubules and interfere with sodium-potassium exchange. The result is excretion of sodium, but a retention of potassium. 1. Edema 2. Hypertension 3. Hyperaldosteronism 4. Used frequently with diuretics (thiazides) drugs ADMINISTRATION CONSIDERATIONS 1. Take with food or milk 2. Avoid salt substitutes 3. Avoid excessive ingestion of foods high in potassium 4. When administering SPIRONOLACTONE (Aldactone) to CHILDREN, crush tablet and mix in flavored syrup as oral suspension. CONTRAINDICATIONS

1. 2. 3. 4. 5. 6. 7. 8. 9.

Serum potassium levels greater than 5.5 mEq/mL Concomitant use with other potassium-sparing diuretics Fluid and electrolyte imbalances Anuria Acute and chronic renal insufficiency Diabetic neuropathy Hypersensitivity Impaired hepatic function Caution in client with DM.

SPECIFIC DRUG/FOOD INTERACTIONS 1. May potentiate hypotensive effects of antihypertensive agents 2. Increased risk of hyperkalemia with other potassium-sparing Diuretics 3. May increase serum blood levels of lithium due to decreased renal clearance. 4. Reduced effects of DIGOXIN if administered with amiloride. 5. ASPIRIN may slightly decrease response of spironolactone. 6. ANTIDIABETIC DRUGS may need adjustments as TRIAMTERENE may increase blood glucose levels 7. CORTICOSTEROIDS may increase electrolyte depletion. 8. Triamterene (dyrenium) decreases effects of FOLIC ACID, increases toxicity risk for amantadine. SPECIFIC FOOD INTERACTIONS: administering spironolactone with food increases its absorption. SIGNIFICANT LABORATORY STUDIES 1. Monitor electrolytes (especially potassium),(SE: Transient elevated) creatinine, and BUN 2. Digoxin level 3. Triamterene may interfere with enzyme assays. SIDE EFFECTS & ADVERSE EFFECTS CNS: Headache, weakness, dizziness, and orthostatic hypotension. GI: nausea, vomiting, diarrhea, & constipation DERM: photosensitivity (triamterene [dyrenium]) F&E: hyperkalemia GU: kidney stones (triamterene) HEMATOLOGIC: dyscrasias ( triamterene & spironolactone) ENDOCRINE : gynecomastia, irregular menses, or amenorrhea (spironolactone) Or toxicity: 1. Aplastic anemia and thrombocytopenia 2. Hyperkalemia PREGNANCY CATEGORY B: 1. Amiloride (midamor) 2. Eplenerone (inspra) PREGNANCY CATEGORY D: 1. Spironolactone (aldactone) 2. Triamterene (dyrenium) NURSING CONSIDERATIONS/ CLIENT TEACHING

1. Monitor VS, UO, dehydration & electrolyte imbalance, periodic serum electrolytes (BUN & creatinine) 2. Administer with meals to prevent GI upset. 3. Discontinue potassium supplements 4. Observe closely ELDERLY and DEBILITATED CLIENTS for drug-induced diureis and hyperkalemia (nausea, diarrhea, abdl cramps, tachycardia followed by bradycardia). 5. Take medication with food to avoid GI UPSET with all meds except TRIAMTERENE. 6. Avoid consumption of large quantities of foods high in potassium. 7. Report any mental confusion or lethargy. 8. Side effects usually disappear after the drug is discontinued except GYNECOMASTIA may persist. 9. With SPIRINOLACTONE, maximal diuresis may not occur until day 3 of therapy and diuresis may continue 2-3 days after the drug is stopped. 10. TRIAMTERENE may turn the urine BLUE. 11. AVOID SALT SUBSTITUTES because they contain potassium. 12. Avoid exposure to direct sunlight. POTASSIUM-LOSING DIURETICS: THIAZIDE AND THIAZIDE-LIKE DIURETICS THIAZIDE belongs to a cheml class of drugs called the SULFONAMIDES. THIAZIDE-LIKE have a slightly diff. cheml structure but works in the same way. Considered to be MILD DIURETICS. ACTION AND USE Thiazide diuretics work to block the chloride pump in the distal convoluted tubule. Inhibits reabsorption of sodium and chloride ions in the ascending portion of the loop of Henle and the early distal tubule of the nephron. Because these segments of the tubule are impermeable to water, there is little increase in the volume of urine produced, but it will be SODIUM RICH, A SALURETIC EFFECT. Frequently used alone or in combination w/ other drugs to treat hypertension. Not effective for immediate diuresis. 1. EDEMA (CHF, renal dysfunction, cirrhosis, glucocorticoid, estrogen therapy) 2. Hypertension 3. Diabetes insipidus DRUGS ADMINISTRATION CONSIDERATIONS 1. Take the medication early in the day to avoid nocturia. 2. Administer with food or milk to prevent GI upset 3. Are ineffective if creatinine clearance level is less 30 mL/min. 4. Allow 2-4 weeks for maximum antihypertensive effect. 5. Metolazone (Zaroxylin) is not recommended in children because safety has not been established. CONTRAINDICATIONS 1. Hypersensitivity to thiazide o sulfonamide derivatives. 2. Clients with anuria. 3. Use cautiously in client with severely impaired renal or hepatic function.

4. Contraindicated in pregnancy, women who breastfeed should not use thiazide diuretics. SPECIFIC DRUG/FOOD INTERACTIONS 1. Concomitant use w/ lithium will increase SERUM LITHIUM LEVELS. 2. Thiazide diuretics decrease the effectiveness of HYPERURICEMIC AGENTS, SULFONYLUREAS, and INSULIN. 3. There is an additive effect if used with loop diuretics. 4. NSAIDs cause a decreased thiazide diuretic effect. 5. BILE ACID RESINS decrease absorption of thiazide. 6. Thiazide diuretics may increase the hypersensitivity to allopurinol. 7. Concurrent use with cardiac glycosides increases hypokalemia and risk of cardiac glycoside toxicity. 8. Concurrent use with CORTICOSTEROIDS may cause additive hypokalemia. 9. Excessive intake of LICORICE can cause additive hypokalemia. SPECIFIC FOOD INTERACTION: none reported SIGNIFICANT LABORATORY STUDIES 1. May alter serum electrolytes, especially lowering K. 2. May increase serum URATE, GLUCOSE, CHOLESTEROL, TRIGLYCERIDE, BUN, and CREATININE. 3. May interfere with tests for parathyroid function. 4. Decreased protein-bound iodine levels w/o thyroid dysfunction. SIDE EFFECTS/ ADVERSE EFFECTS CNS: dizziness, drowsiness decreased libido DERM: rash & photosensitivity ENDO: hyperglycemia F & E: Hypokalemia, DHN, hyperuricemia GI: N&V, Diarrhea, anorexia HEMATOLOGIC: blood dyscrasias & jaundice AE: 1. Renal failure 2. Aplastic anemia 3. Agranulocytosis 4. Thrombocytopenia 5. Anaphylactic reaction PREGNANCY CATEGORY B: 1. Hydrochlorothiazide 2. Chlorothiazide 3. Methyclothiazide 4. Metolazone PREGNANCY CATEGORY D: 1.Hydroflumethiazide NURSING CONSIDERATIONS/ CLIENT EDUCATION 1. Monitor VS for hypotension & tachycardia. 2. Monitor serum electrolytes, calcium & uric acid levels

3. Monitor & record Body Wt. at regular intervals at the same time of day and same scale. 4. Monitor I&O. 5. Assess indicators of DHN: (thirst, poor skin turgor, coated tongue) 6. Assess for inadequate tissue perfusion & weakness, decreased muscle strength, restlessness, anxiety, and agitation. 7. Eat foods high in K to prevent hypokalemia 8. Restrict sodium intake; do not use salt substitutes if taking potassium supplement 9. Avoid DHN by avoiding alcohol & caffeine beverages and replacing Fluids during exercise/hot weather. 10. Avoid exposure to intense heat as w/ baths, showers, & electric blankets. 11. Take small frequent amts. Of ice chips/clear liquids if vomiting. 12. Replace fluids w/ fruit juice or bouillon if diarrhea occurs. 13. Take doses in morning and early afternoon to avoid nightmare urination & interruption of sleep. 14. Change positions slowly to avoid dizziness & orthostatic hypotension. 15. Weigh self daily & report sudden wt. gain/ losses. 16. If diabetic, check blood glucose periodically. POTASSIUM-LOSING: LOOP DIURETICS Are so named because they work in the loop of henle. Also referred to as high-ceiling diuretics because they cause a greater degree of diuresis than other diuretics do. powerful diuretic effect causes loss of water, sodium, & K. Most potent and are used in acute & chronic conditions not responsive to milder diuretics. Works even in the presence of acid-base disturbances, renal failure, electrolyte imbalance/nitrogen retention. Ethacrynic acid (edecrin)- first loop diuretic, used less frequently because of improved potency & reliability of the newer drugs. Furosemide (lasix)- most commonly used. Action & use Blocks the chloride pump in the ascending loop of henle, where normally 30% of all filtered sodium is reabsorbed. Action decreases the reabsorption of sodium and chloride. Have a similar effect on the descending loop of henle and in the distal convoluted tubule, resulting in COPIOUS AMT. OF SODIUM-RICH URINE. drug of choice when a rapid and extensive diuresis is needed, because they can produce a loss of fluid of up to 20 lb/d Have an effect only on the blood that reaches the nephrons. 1. Edema r/t CHF 2. Hepatic/renal disease 3. Hypertension 4. hypercalcemia drugs Administration consideration/ contraindications 1. Take early in the day to avoid nocturia. 2. Give intravenous doses slowly over 1-2 mins; rapid injection may cause hypotension. 3. For IV infusion, dilute in 5% dextrose in water, 0.9% NaCl, or Lactated Ringers ; use infusion fluids w/in 24 hours.

4. Administer IV FUROSEMIDE (lasix) SLOWLY. As hearing loss can occur if injected rapidly. 5. Anuria 6. Electrolyte depletion 7. Hypersensitivity, cross sensitivity w/ thiazides & sulfonamides 8. Hepatic coma Specific drug/food interaction 1. Interact w/ AMINOLYCOSIDES causing OTOTOXICITY. 2. Interact w/ DIGITALIS (increasing digitalis-induced arrhythmias), indomethacin, lithium, ethacrynic acid, salicylates, and NSAIDs (may decrease efficacy of loop diuretics, tubocurarine, succinylcholine, other antihypertensives (additive hypotensions). 3. An additive effect w/ thiazide & thiazide-like diuretics. 4. Interact w/ ANTICOAGULANTS (increase anticoagulant activity), PROPANOLOL (increased plasma levels), SULFONYLUREAS (Hyperglycemia), CISPLATIN (ototoxicity), and PROBENECID. 5. Increase risk for lithium toxicity. Specific Food Interactions: 1. Taking ethacrynic acid (edecrin) w/ food/milk wii increase urination. 2. Licorice may lead to added K loss. Significant laboratory studies 1. Monitor for electrolyte imbalance especially Na & K. 2. Monitor for hemoglobin and hematocrit as these may be increased due to hemoconcentration; monitor platelet count. 3. Monitor for blood dyscrasias, liver, or kidney damage. 4. Monitor for blood glucose levels and lipids for possible drug interaction. 5. Monitor lithium levels, if taking lithium for elevation. Side effects/adverse effects CNS: Dizziness, headache, orthostatic hypotension, weakness GI: N&V, adbl pain, elevated lipids w/ decreased HDL, pancreatitis, anorexia, constipation. GU: excessive urination, nocturia, urinary bladder spasms photsensitivity, sulfonamide allergt, and ototoxicity (tinnitus, hearing impairment, deafness, vertigo, & sense of fullness in ears) SKIN: dermatitis, urticaria, pruritus, & muscle spasm Severe watery diarrhea- SE OF ETHACRYNIC ACID. A. ELECTROLYTE IMBALANCES: hyponatremia, hypochloremia, hypokalemia, hypomagnesemia, hypocalcemia, hyperuricemia. B. Thrombocytopenia, systemic vasculitis, interstitial nephritits, thrombophlebitis, agranulocytosis, and aplastic anemia. PREGNANCY CATEGORY B: 1. TORSEMIDE (demadex) PREGNANCY CATEGORY C: 1. BUMETANIDE (bumex) 2. FUROSEMIDE (lasix) PREGNANCY CATEGORY D 1. ETHACRYNIC ACID (edecrin) NURSING CONSIDERATION 1. Monitor VS for hypotension & tachycardia. 2. Monitor serum electrolytes, calcium & uric acid levels

3. Monitor & record Body Wt. at regular intervals at the same time of day and same scale. 4. Monitor I&O. 5. Assess indicators of DHN: (thirst, poor skin turgor, coated tongue) 6. Assess for inadequate tissue perfusion & weakness, decreased muscle strength, restlessness, anxiety, and agitation. CLIENT EDUCATION 1. Eat foods high in K to prevent hypokalemia 2. Restrict sodium intake; do not use salt substitutes if taking potassium supplement 3. Avoid DHN by avoiding alcohol & caffeine beverages and replacing Fluids during exercise/hot weather. 4. Avoid exposure to intense heat as w/ baths, showers, & electric blankets. 5. Take small frequent amts. Of ice chips/clear liquids if vomiting. 6. Replace fluids w/ fruit juice or bouillon if diarrhea occurs. 7. Take doses in morning and early afternoon to avoid nightmare urination & interruption of sleep. 8. Change positions slowly to avoid dizziness & orthostatic hypotension.(A bp fall of more than 10-15 mmHg systolic pressure/ fall of more than 10 mmHg diastolic pressure & a 10-20% increase in heart rate. 9. Weigh self daily & report sudden wt. gain/ losses. 10. Report ringing in ears immediately. 11. Do not use loop diuretics while BREASTFEEDING 12. Eliminate LICORICE from diet. Potassum-losing: carbonic anhydrase inhibitors Are relatively mild diuretics. Enzyme CARBONIC ANHYDRASE= catalyst for the formation of sodium bicarbonate, w/c is stored as the alkaline reserve in the renal tubule, and for the excretion of hydrogen, w/c results in a slightly acidic urine. Action & use Blocks the effects of carbonic anhydrase slows down the movement of hydrogen ions; as a result more sodium and bicarbonate are lost in the urine . Promotes excretion of bicarbonate, sodium, potassium, & water. Results in slightly acidic urine. Used as adjuncts to other diuretics when a more intense diuresis is needed. 1. Edema (CHF) 2. Open angle glaucoma (inhibition of carbonic anhydrase decreases secretion of aqueous humor of the eye & decrease intraocular pressure). 3. Epilepsy 4. Metabolic alkalosis 5. Acute altitude sickness drugs Administration consideration/ contraindication 1. Increasing the dose does not appear to increase diuresis 2. Do not administer w/ high dose aspirin 3. Intramuscular administration is not recommended 4. Pregnancy 5. Narrow angle/ acute glaucoma 6. Any situation w/ decreased Na &/ K levels 7. Marked kidney/ liver dysfunction 8. Cautionary use in client w/ COPD/ LACTATION SIGNIFICANT DRUG/ FOOD INTERACTIONS

aspirin may cause accumulation & toxicity of azetolamide May increase levels of cyclosporine & decreased levels of primidone. Increased excretion of lithium Decreased renal clearance of amphetamines, anticholinergics, mecamylamine, procainamide, quinidine, and tricyclic antidepressants (TCAs) (toxicity) Significant Food Interactions: none reported Significant laboratory studies 1. Obtain platelet and CBC prior to and periodically during therapy; may decrease hemoglobin & hematocrit 2. Monitor serum electrolytes 3. May cause false-positive urine protein tests. 4. May decrease thyroid iodine uptake 5. May increase uric acid level Side effects/ adverse effects CNS: drowsiness, depression, paresthesias DERM: Rash, photosensitivity, urticaria F&E: acidosis, hypokalemia GI: anorexia, metallic taste Hematologic: leukopenia PREGNANCY CATEGORY C 1. Metabolic acidosis 2. Anaphylaxis 3. Bone marrow depression 4. Thrombocytopenia, purpura, hemolytic anemia, leukopenia, pancytopenia, & agranulocytosis. 5. Severe reactions to sulfonamides including steven-johnson syndrome, toxic epidermal necrolysis, fulminant hepatic necrosis, coma, and death have occured Nursing considerations/ client education 1. monitor for s/sx of DHN, I&O 2. Assess for alterations in skin integrity 3. Assess for edema 4. Assess vital signs and daily weight 5. Assess cardiovascular & respiratory status 6. Assess changes in LOC and activity level 7. Daily assessment of high salt-containing foods 8. Fluid restriction as ordered 9. Do not take aspirin-containing medications 10. Report symptoms of anorexia, lethargy, or tachypnea 11. Use caution while driving/performing tasks that require alertness, coordination/ physical dexterity because of risk of drowsiness. 12. Monitor for signs of renal calculi 13. Follow up schedule lab tests are important 14. Weigh self daily at the same time of the day & report any acute weight gain/ loss 15. Be aware of and avoid high-sodium foods & beverages; eat foods high in potassium instead Osmotic diuretics Pulls water into the renal tubule w/o sodium loss. Works in the proximal tubule & increase osmotic pressure of lomerular filtrate, w/c inhibits tubular reabsorption of water & electrolytes. Decreases intraocular pressure

1. 2. 3. 4.

Action & use Mannitol for example, is a sugar that is not well absorbed by the tubules; it acts to pull large amounts of fluid into the urine due to the OSMOTIC PULL exerted by the large sugar molecule. Because the tubule is not able to reabsorb all of the sugar pulled into it, large amounts of fluid are lost in the urine. It also pulls fluid into the vascular system from extravascular spaces, including the aqueous humor. 1. Acute renal failure 2. Edema 3. GU irrigant for transurethral procedures 4. Increased intracranial/ intraocular pressure (glaucoma) drugs Administration considerations/ contraindications 1. Medications are administered IV by slow infusion 2. Urea turns to ammonia if left standing 3. Do not infuse with blood or blood products 4. Mannitol crystallizes @ low temperatures 5. For maximum reduction of intraocular pressure, mannitol should be given 1-1.5 hours before surgery. 6. Severely impaired renal function 7. Marked DHN 8. Breast feeding 9. Hepatic failure 10. Active intracranial bleeding 11. Anuria 12. Severe pulmonary congestion 13. Severe CHF Significant drug/food interactions 1. Decreased serum lithium levels 2. Use w/ cardiac glycosides may cause an increased possibility of digitalis toxicity. 3. Increase the effects of other diuretics. Significant Food interactions: none reported. Significant laboratory studies 1 monitor BUN and electrolytes frequently. Side effects/ Adverse effects Pregnancy category C CNS: headache, confusion, convulsion, blurred vision CV: tachycardia, chest pain, pulmonary edema LOCAL: thrombophlebitis Nursing considerations/ client education 1. Maintain adequate hydration 2. Monitor F&E balance 3. Monitor BUN 4. Indwelling catheter should be used in comatose clients for accurate I &O 5. Monitor I &O & VS hourly while on MANNITOL 6. Measure daily weight 7. Monitor renal function, fluid balance, serum, and urinary Na & K levels 8. Assess for signs of decreasing ICP if appropriate 9. Monitor lung & heart sounds for signs of pulmonary edema 10. Monitor daily weight and report sudden weight gain or loss.

11. 12. 13. 14.

Report immediately pain in chest/legs, SOB, or apnea Change position slowly to prevent dizziness/ orthostatic hypotension Drink only fluids ordered even if thirsty and/or experiencing dry mouth Have family monitor change in neuro status such as decreased LOC