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Pitfalls in Diuretic Use Metabolic Adverse Reactions

Some commonly used diuretics. Thiazides and Thiazide analogsBendroflumethiazide, hydrochlorothiazide, indapamideLoop diureticsFurosemide, bumetanide, torasemide (long half-life)Potassium-sparing diureticsAmiloride, spironolactone, triamtereneCarbonic anhydrase inhibitorsAcetazolamide (specific use).

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Pitfalls in Diuretic Use Metabolic Adverse Reactions

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    1. Pitfalls in Diuretic Use Metabolic Adverse Reactions Iwan Darmansjah, MD

    2. Some commonly used diuretics Thiazides and Thiazide analogs Bendroflumethiazide, hydrochlorothiazide, indapamide Loop diuretics Furosemide, bumetanide, torasemide (long half-life) Potassium-sparing diuretics Amiloride, spironolactone, triamterene Carbonic anhydrase inhibitors Acetazolamide (specific use)

    3. Adverse reactions to diuretics well known Elderly people most affected Mainly prescribed for hypertension and cardiac insufficiency Thiazide as antihypertensive should not be called diuretic, because of the small doses used, and is not diuretic.

    4. URINARY ELECTROLYTE COMPOSITION DURING DIURESIS

    5. Loop-diuretic as Fluid-mover Furosemide increases urine vol 8 x Normal Thiazide (diuretic dose) 3 x N Potassium-sparing diuretic 2 x N

    6. Main Indications of furosemide Removing edema fluid from: Feet and legs, ascites, pulmonary interstitial and alveoli, whole body tissue edema Acute and chronic Heart Failure Forced diuresis

    7. HCT dose As diuretic: 50-100 mg As antihypertensive dose much smaller: 6.25 mg (as in Lodoz) 12.5 mg/day No problem of hyponatremia, nor hypokalemia No need of routine K supplementation Most metabolic adverse reactions of thiazide was reported from the 70s late 80s, when the doses used were large (50-100 mg/day or more).

    9. Hyponatremia Hyponatremia is the most frequent electrolyte abnormality among diuretic (all diuretics) users. It may be fatal. Furosemide has the strongest natriuretic effect, and therefore the most frequent adverse reaction. Factors: age, female, malnutrition, renal failure, combination with NSAID, ACE-inhib. When severe renal failure: hyperkalemia, hyperphosphatemia, hyperuricemia. .

    10. Hypokalemia Hypokalemia is the most feared among furosemide, and even low-dose thiazide users. This fear is unfounded and results in overuse of K salts as a preventive in all patients receiving long term furosemide, which may result in hyperkalemia.

    11. Nature of Adverse Reactions Hyponatremia: (when mild, asymptomatic) Postural hypotension Weakness, vomiting, mental confusion, coma, convulsion Neurological complication when < 120 mmol/L Hypokalemia: Cardiac arrhytmia (QRS widening) Excessive water loss (dehydration)

    12. Drugs that may alter K levels Hypokalemia Thiazide as a diuretic (not if used as antihypertensive) Loop diuretic Mineralocorticoids (fludrocortisone) Cathartics Adrenergics, theophylline (high dose) Hyperkalemia KCL tablets Potassium sparing diuretics ACE-inhibitors NSAID (especially when renal impairment)

    13. Some Mechanisms (1) ACE-inhib may increase serum K by: Reducing angiotensin-II mediated release of aldosterone, which reduces K excretion in the distal tubules. Fludrocortisone produces hypokalemia by increasing K renal excretion with Na absorption in the distal tubule.

    14. Some Mechanisms (2) Adrenergics: stimulate K uptake by muscles redistribution of K (usually mild) Furosemide depends on renal excretion; Bumetanide does not, because metabolized

    15. Treatment of Hyponatremia Slow infusion of isotonic or hypertonic NaCl solution. Restriction of water intake. Precaution: when checking K level, one should include Na.

    16. Treatment of Hypo- and Hyper-kalemia Severe hypo- or hyper-kalemia must be treated fast with cardiac monitoring. Hypo: Slow infusion of KCL solution. Hyper: Infusion of glucose and insulin (stimulates K uptake in the cell) Also: anion exchange resin to bind K ion.

    17. Conclusion Diuretics are beneficial for many diseases It may also cause fatal adverse reactions (elderly!) Monitoring of electrolyte levels are needed Judicious use is warranted

    18. E-mail: <puko98@indosat.net.id> Homepage: <http://www.iwandarmansjah.web.id> Thank you !

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