Diuretics and RAAS antagonists

Question 1

3 goals of HF management with pharmacotherapy

Answer 1

• Reduction of congestion
  
  • Modulate neurohormonal activation
  • Improve flow

Question 2

Which diuretics are the most efficacious, why?

Answer 2

Loop

Question 3

Which classes of drugs are K+ sparing? Na + sparing? K+ wasting?

Answer 3

Na+ sparing = Aldosterone
K+ wasting = Loop and Thiazides
K+ sparing = Aldo-antagonists, ACE-I, and ARB

Question 4

In HFrEF acute conditions, which drugs would you use?

Answer 4

IV diuresis!!!
Nitrates (if BP allows)
CPAP/BiPAP (if SOB)
Pressors (if ↓↓↓CO, shock

Question 5

In HFpEF acute conditions, which drugs would you use?

Answer 5

IV diuresis!!!
Nitrates (if BP allows)
CPAP/BiPAP

Question 6

Diuretics used to treat what?

Answer 6

Volume overload
(SV-Vntricular EDP grap gets moved to left)

Diuretics will:
 ↑ Salt (+Water) Excretion → 
↓ Intravasc Fluid Vol → 
↓ Venous congestion → 
↓ Dyspnea, Edema

Lowers preload (LVEDP)

Question 7

Are diuretics used chronically or acutely?

Answer 7

can be both

Question 8

Most common diuretic

Answer 8

Furosemide

• Torsemide or bumetanide have more reliable absorption

Question 9

Describe when/how you would initially use ACEIs

Answer 9

Started during or after optimization of diuretic therapy at low doses

Question 10

What do ACEIs produce?

Answer 10

Produce vasodilation
↓ aldosterone activation
Plus antiremodeling effect

Question 11

True/False, ARBs used in conjuction with ACEIs will benefit from the dual therapy

Answer 11

NO!

No apparent benefit from dual therapy

Question 12

What drug is added to therapy for LVEF < 30-35%, optimized on ACEI/ARB and β-blocker therapy

Answer 12

Aldosterone Antagonists

- ACEI/ARB aldosterone block is incomplete

Question 13

what type of aldosterone antagonist is preferred?

Answer 13

Spironolactone preferred if tolerated - if endocrine side effects (gynecomastia) can use eplerenone

Question 14

Diuretic Agents you would be stupid not to know

Answer 14

#11: Hydrochlorothiazide
#14: Furosemide (Lasix®)
#70: Spironolactone (Aldactone®)

Question 15

Nearly all diuretic agents exert their effects at______ surface of renal tubule cells.

Answer 15

luminal (urine)

Question 16

Na+ is the major extracellular cation and its movement between compartments is controlled by regulated active transport via ________ activity at the _______ surface

Answer 16

Na+-K+-ATPase

interstitial (blood)

Question 17

Compensatory changes in HF

Answer 17

↓ CO →

1. ↑ Sympathetic discharge
   (baroreceptor response)
2. ↑ Renin release
   (RAAS response)
3. Na+ reabsorption → ↑ fluid retention

(remodeling caused by AII can cause chronic harm)

Question 18

Diuretic mechanism of:

thiazides, furosemide, triamterene

Answer 18

Interactions with membrane transport proteins

Question 19

Diuretic mechanism of:
(acetazolamide)
or
(spironolactone)

Answer 19

Intxn of enzymes (acetazolamide)
or
hormone receptors (spironolactone)

Question 20

Diuretic mechanism of:

Mannitol

Answer 20

Osmotic effects preventing water reabsorption

Question 21

True / False, diuretics act via inhibition of Na+-K+-ATPase

Answer 21

False

Diuretic agents decrease Na+ reabsorption at various sites in the nephron

Question 22

K+ sparing diuretics do what?
K+ wasting diuretics do what?
- examples

Answer 22

K+ sparing diuretics
- decrease K+ excretion in collecting duct
K+ wasting diuretics
- increase K+ excretion in ascending LOH

Question 23

K+ sparing diuretics

- examples

Answer 23

Aldosterone antagonists

Question 24

K+ wasting diuretics

- examples

Answer 24

Loop agents

Thiazides

Question 25

Loop diuretic examples

• what do they do?
• examples

Answer 25

Inhibit NaCl transport (Na+-K+-2Cl–transporter)

Furosemide
Bumetanide
Torsemide

Question 26

Loop diuretics Associated with increase in ____and ___ excretion (diminish lumen-positive potential)

Answer 26

Mg++, Ca++

Question 27

If Loop diuretics such as Furosemide has a lack of response, what drugs can you switch to?
What about if there is a sulfa allergy?

Answer 27

Switch to bumetanide or torsemide –> more reliable bioavailability and longer duration of action

Ethacrynic acid can be used if sulfa allergy

Question 28

Which aldosterone antagonist improves survival in some pts with systolic HF?

Answer 28

Spironolactone

Question 29

What type of drug is most efficacious in HF?

Answer 29

Loop diuretics