DIURETICS

BY-
DR. Saurabh kansal
DEPT. OF PHARMACOLOGY
MSY MEDICAL COLLEGE
Meerut
 Anatomy and Physiology of Renal
system
► Remember the nephron is the most
important part of the kidney that regulates
fluid and electrolytes.

► Urine formation:
1. Glomerular filtration rate = 180L/day
2. Tubular re-absorption (around 98%)
3. Tubular secretion
► How could urine output be increased ?
↑ Glomerular filtration Vs ↓ Tubular reabsorption
(the most important clinically)
o If you increase the glomerular filtriation  increase
tubular reabsorption (so you cant use glomerular
filtiration)

► Purpose of Using Diuretics

1. To maintain urine volume ( e.g.: renal failure)

2. To mobilize edema fluid (e.g.: heart failure,liver

failure, nephrotic syndrome)

3. To control high blood pressure.

► Percentage of reabsorption in each
segment:
 Proximal convoluted tubule 60-70%

 Thick portion of ascending limb of the loop of

Henle. 25%

 Distal convoluted tubule 5-10%

 Cortical collecting tubule 5% (Aldosterone and

ADH)
 Physiology of tubular reabsorption

The filtirate
here is
isotonic

The filtirate
here is
hypertonic
 Classification of Diuretics
► The best way to classify diuretics is to look for their Site of
action in the nephron

A) Diuretics that inhibit transport in the Proximal

Convoluted Tubule ( Osmotic diuretics, Carbonic
Anhydrase Inhibitors)

B) Diuretics that inhibit transport in the Medullary

Ascending Limb of the Loop of Henle( Loop diuretics)

C) Diuretics that inhibit transport in the Distal Convoluted

Tubule( Thiazides : Indapamide , Metolazone)

D) Diuretics that inhibit transport in the Cortical Collecting

Tubule (Potassium sparing diuretics)
 A. Diuretics that inhibit transport in the
Convoluted Proximal Tubule
1. Osmotic Diuretics (e.g.: Mannitol)
Mechanism of action: They are hydrophilic compounds that are easily
filtered through the glomerulus with little re-absorption and thus increase
urinary output via osmosis.
PK: Given parentrally. If given orally it will cause osmotic diarrhea.
Indications:
- to decrease intracranial pressure in neurological condition
- to decrease intraocular pressure in acute glaucoma
- to maintain high urine flow in acute renal failure during shock
Adverse Reactions:
- Extracellular water expansion may complicate heart failure and produce
pulmonary edema.
- Dehydration
- Hypernatremia due to loss more water than sodium
contraindication:
1- heart failure
2- renal failure
2. Carbonic Anhydrase Inhibitors (Acetazolamide (Oral) ;
Dorzolamide (Ocular) ; Brinzolamide (Ocular)
Mechanism of action Simply inhibit reabsorption of sodium
and bicarbonate.

It prevents the
reabsorption of
HCO3 and Na

• Inhibition of HCO3 reabsorption  metabolic acidosis.

• HCO3 depletion  enhance reabsorption of Na and Cl  hyperchloremea.

• Reabsorption of Na  ↑ negative charge inside the lumen  ↑K secretion

 Clinical uses
• Weak diuretic : because depletion of HCO3  enhance reabsorption of Na and Cl

• In glaucoma :
 The ciliary process absorbs HCO3 from the blood.
 ↑HCO3  ↑aqueous humor.
 Carbonic anhydrase inhibitors prevent absorption of HCO3 from the blood.

• Urinary alkalinization : to increase renal excretion of weak acids e.g.cystin and uric acid.

• In metabolic alkalosis.

• Epilepsy : because acidosis results in ↓seizures.

• Acute mountain sickness.

• Benign intracranial hyper tension.

Dorzolamde and brinzolamide are mixed with β blockers

(Timolol) to treat glaucoma (as topical drops)
► Side Effects of Acetazolamide:
Sedation and drowsiness; Hypersensitivity
reaction (because it contains sulfur)
Acidosis (because of decreased absorption
of HCO3 ) ; Renal stone (because of alkaline
urine); Hyperchloremia, hyponatremia and
hypokalemia
B. Diuretics Acting on the Thick Ascending Loop
of Henle (loop diuretics) High ceiling (most efficacious)
► e.g. Furosemide (LasixR), Torsemide, Bumetanide
(BumexR), Ethacrynic acid.
► Phrmacodynamics:
1) Mechanism of Action : Simply inhibit the coupled
Na/K/2Cl cotransporter in the loop of Henle. Also,
they have potent pulmonary vasodilating effects (via
prostaglandins).
2) They eliminate more water than Na.
3) They induce the synthesis of prostaglandins in kidney
and NSAIDs interfere with this action.
They are the best diuretics for 2 reasons:
1- they act on thick ascending limb which has large capacity of reabsorption.
2- action of these drugs is not limited by acidosis
In loop diuretics and
thiazides :
The body senses the loss of So the body will
Na in the tubule. increase synthesis of
aldosterone leading
This lead to compensatory to :
mechanism (the body will try 1- increase Na
to reabsorb Na as much as absorption
possible) 2- hypokalemia
3- alkalosis
2. Side effects:.
Ototoxicity; Hypokalemic metabolic
alkalosis; hypocalcemia and
hypomagnesemia; hypochloremia;
Hypovolemia; hyperuricemia (the drugs are
secreted in proximal convoluted tubule so
they compete with uric acid’s secretion)
hypersensitivity reactions(contain sulfur)

3. Therapeutic Uses
a) Edema (in heart failure, liver cirrhosis,
nephrotic syndrome)
b) Acute renal failure
c) Hyperkalemia
d) Hypercalcemia
 Loop
diuretics

:Torsemide Bumetanide (Bumex®)

:Furosemide .Taken orally Taken orally
Taken orally or i.v Better absorption times potent than 40
.furosemide
If taken orally only 50 Fast onset of action
% is absorbed Fast onset
t1/2↑ Short duration of action

Dosage of loop diuretics:

Furosemide 20-80 mg
Torsemide 2.5-20 mg
Bumetanide 0.5-2.0 mg
C. Diuretics that Inhibit Transport in the Distal
Convoluted Tubule (e.g.: Thiazides and
Thiazide-like (Indapamide; Metolazone)
► Pharmacodynamics:
 Mechanism of action: Inhibit Na+ via inhibition
of Na+/Cl- cotransporter.
 They have natriuretic action.
Side effects:
► No ototoxicity; hypercalcemia due to ↑PTH, more
hyponatremia; hyperglycemia (due to both impaired
pancreatic release of insulin and diminished utilization of
glucose) hyperlipidemia and hyperurecemia ; hypokalemic
metabloic alkalosis
► Clinical uses:
a) Hypertension Drug of Choice
(Hydrochlorthiazide; Indapamide (NatrilexR)
b) Refractory Edema(doesn’t respond well to
ordinary treatment) together with the Loop diuretics
(Metolazone).
c) Nephrolithiasis (Renal stone) due to idiopathic
hypercalciuria .
d) hypocalcemia.
e) Nephrogenic Diabetes Insipidus. (it decreases
flow of urine  more reabsorption)
‫هذا التفسير الوحيد اللي لقيته‬
thiazides ‫الستخدام‬

 Indapamide is a potent vasodilator

► D. Diuretics that inhibit transport in the
Cortical Collecting Tubule (e.g. potassium
sparing diuretics).
Classification of Potassium Sparing Diuretics:
A) Direct antagonist of mineralocorticoid
receptors (Aldosterone Antagonists e.g
spironolactone (AldactoneR) or
B) Indirect via inhibition of Na+ influx in the
luminal membrane (e.g. Amiloride, Triametrene)

THEY ARE VERY IMPORTANT TO BALANCE K + IN THE BODY

Spironolactone (AldactoneR)

► Syntheticsteroid acts as a competitive

antagonist of aldosterone with a slow onset of
action.
► Mechanism of action: Aldosterone cause
↑K and H+ secretion and ↑Na reabsorption.
► The action of spironolactone is the opposite
Clinical Uses of K+ sparing Diuretics:

 In states of primary aldosteronism (e.g. Conn’s

syndrome, ectopic ACTH production) of secondary
aldosteronism (e.g. heart failure, hepatic cirrhosis,
nephrotic syndrome)
 To overcome the hypokalemic action of diuretics
 Hirsutism (the condensation and elongation of
female facial hair) because it is an
antiandrogenic drug.
Side effects:
► Hyperkalemia (some times it’s useful other wise it’s a
side effect).
► Hyperchloremic (it has nothing to do with Cl)
metabolic acidosis
► Antiandrognic effects (e.g. gynecomastia: breast
enlargement in males, impotence) by spironolactone.
► Triametrene causes kidney stones.
► Diuretics Combination preparations
these are anti-hypertensive drugs:
DyazideR = Triametrene 50 mg + Hydrochlorothiazide HCT 25 mg
AldactazideR= Spironolactone 25 mg + HCT 25 mg
ModureticR = Amiloride 5 mg + HCT 50 mg
► Note : HCT to decrease hypertension and K sparing
diuretics to overcome the hypokalemic effect of HCT
► Contraindications: Oral K administration and using of ACE
THANK YOU