CPT S9 - Diuretics Flashcards by Jess Sidney

What are the physiological mechanisms the kidney is responsible for?

Regulatory
Excretory
Endocrine
Metabolism

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What regulatory functions is the kidney responsible for?

Fluid balance
Acid-base balance
Electrolyte balance

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What endocrine functions is the kidney responsible for?

Renin-Angiotensin-Aldosterone
Erythropoetin
Prostaglandins

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What excretory mechanisms does the kidney control?

Waste product excretion
Drug elimination;
-Glomerular filtration
-Tubular secretion

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What metabolic functions is the kidney responsible for?

Vitamin D
Polypeptides;
-Insulin
-PTH

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What are some ADRs for Thiazides?

Gout

Erectile dysfunction

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What are some ADRs for furosemide?

Ototoxicity

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What are some ADRs for spironolactone?

Hyperkalaemia

Painful gynaecomastia

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What are some ADRs for bumetanide?

Myalgia

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Which diuretics do ACE inhibitors interact with, and what is the result of this?

K sparing diuretics
Causes increased hyperkalaemia
Leads to cardiac problems

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Which diuretics does aminoglycosides interact with, and what is the result of this?

Loop diuretics
Ototoxicity
Nephrotoxicity

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Which diuretics does digoxin interact with, and what is the result of this?

Thiazides and loop diuretics
Hypokalaemia
Leads to increased digoxin binding and toxicity

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Which diuretics do β-blockers interact with, and what is the result of this?

Thiazide diuretics
Hyperglycaemia
Hyperlipidaemia
Hyperuricaemia

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Which diuretics do steroids interact with, and what is the result of this?

Thiazides and loop diuretics

Increased risk of hypokalaemia

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Which diuretics does carbamazepine interact with, and what is the result of this?

Thiazide diuretics

Increased risk of hyponatraemia

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What is the recommended treatment for heart failure?

Loop diuretics
Thiazide diuretics - as an add-on
(Spironolactone - non-diuretic benefits)
ACEi or angiotensin II antagonists
β-blockers

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Why does diuretic resistance occur?

Incomplete treatment of the primary disorder
Continuation of high Na intake
Patient non-compliance
Poor absorption
Volume depletion decreases filtration of diuretics
Volume depletion increases serum aldosterone, which increases Na reabsorption
NSAIDs can reduce renal blood flow

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What is the recommended treatment for hypertension?

Thiazide diuretics
Spironolactone
(Loop diuretics)
ACEi or angiotensin II antagonists
β-blockers

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What is the recommended treatment of decompensated liver disease?

Spironolactone (HUGE doses)

Loop diuretics

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What are some potentially nephrotoxic drugs?

ACEi
Aminoglycosides eg gentamicin
Penicillins
Cyclosporin A
Metformin
NSAIDs

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What are some important things to remember when prescribing to CKD patients?

Avoid nephrotoxins
Reduce dosages in line with GFR if metabolism or elimination via kidneys (except furosemide)
Monitor renal function and drug levels
Uraemic patients more likely to bleed
Hyperkalaemia more likely in CKD

What are some important things to remember when prescribing to elderly patients?

Renal function often over-estimated as creatinine is body mass-dependent
Start low and titrate up cautiously
Polypharmacy more likely

What is the management of hyperkalaemia?

Identify cause

ECG!!

How is hyperkalaemia treated?

Calmcium gluconate
Insulin+dextrose
Calcium resonium
Sodium bicarbonate
Salbutamol

What are some general ADRs for diuretics?

``` Anaphylaxis/rash Hypovolaemia Hypotension Electrolyte disturbance Metabolic abnormalities ```

What are the types and causes of hypertension?

Primary/essential hypertension; -High BP without any single evident cause -90% hypertensive population Secondary hypertension; -High BP with a discrete, identifiable underlying cause -10% hypertensive population

What is the treatment of hypertension?

Identify & treat any underlying cause Identify & treat any CVS risk factors or co-morbidities Lifestyle advice Pharmacological therapy

What is the threshold BP for treatment?

>140/90

Give some examples of lifestyle advice you might give patients with hypertension

``` Maintain normal BMI Reduce salt intake to 30 mins/day Eat >5 fruit/veg per day Reduce fat intake Smoking cessation Relaxation therapies ```

What is the 1st line treatment for hypertension?

ACEi/angiotensin receptor blockers (ARBs) Ca channel blockers Diuretics

Give some ACEi ADRs

Dry cough (10-15%) Angio-oedema Renal railure Hyperkalaemia

Give some examples of ACEi drugs

Lisinopril | Ramipril

Give some examples of ARBs

Losartan Valsartan Candesartan

What are some ADRs for ARBs?

Renal failure | Hyperkalaemia

Give some examples of Ca channel blockers

Amlodipine Diltiazem Verapamil

What are some ADRs for amlodipine?

Sympathetic activation Oedema Flushing, sweating, throbbing headache Gingival hyperplasia

What are some ADRs for verapamil?

Constipation Bradycardia Reduced myocardial contractility

What are some ADRs for diltiazem?

Bradycardia | Reduced myocardial contractility (not as bad as verapamil)

Give an example of a thiazide

Bendroflumathiazide

What are some ADRs for bendroflumethiazide?

``` Hypokalaemia Increased urea and uric acid Impaired glucose tolerance Increased cholesterol and triglyceride Activates RAAS ```

What are some atypical anti-hypertensive drug classes?

``` α-adrenoceptor blockers β-adrenoreceptor blockers Direct renin inhibitors Centrally acting agents Vasodilators ```

What are the properties of α-adrenoceptor blockers?

Selective antagonism at post-synaptic α-1 receptors Reduce peripheral vascular resistance Safe in renal disease Eg Doxazosin

Give some ADRs for α-adrenoceptor blockers

``` Postural hypotension Dizziness Headache Fatigue Oedema ```

Give some properties of β-adrenoreceptor blockers

Reduce heart rate and cardiac output Inhibit renin release Initially TPR increases but returns to normal Eg Atenolol, bisoprolol

Give some ADRs for β-adrenoreceptor blockers

``` Lethargy Impaired concentration Reduced exercise tolerance Bradycardia Cold hands Impaired glucose tolerance Bronchospasm Dry cough ```

What are the properties of direct renin inhibitors?

Low bioavailability | Mainly eliminated unchanged in faeces

Give some examples of centally acting agents

Methyldopa Clonidine Monoxidine

What is rebound hypertension?

Withdrawal of a centrally acting anti-hypertensive agent causes; - Desensitisation of inhibitory α2 receptors - Super-sensitivity of post-synaptic α1 receptors

How may heart failure develop?

Ischaemic heart disease Hypertension Cardiopathies Valve disease

How is heart failure treated?

``` RAAS antagonism; -ACEi -ARB -Aldosterone β-blocker ```