Diuretics

 Description/General Information
o Diuretics are used for two main purposes: to decrease hypertension (lower blood pressure)
and to decrease edema, typically peripheral and pulmonary, in heart failure (HF) and renal
or liver disorders.
o Diuretics are drugs that primarily increase the excretion of sodium. To some extent, they
also increase the volume of urine produced by the kidneys.
o By blocking the absorptive capacity of cells lining the renal tubules for sodium, intravascular
volume and the eventual leaking of fluid from capillaries is reduced and prevented.
o It is used in the management of diseases like glaucoma, hypertension, and edema in heart
failure, liver failure, and renal diseases.

Diuretics: Generic and Brand Names

Here is a table of commonly encountered diuretic agents, their generic names, and
brand names:

Classification Generic Name Brand Name

Thiazide diuretics

bendroflumethiazide Naturetin

chlorothiazide Diuril

Thiazide diuretics hydrochlorothiazide HydroDIURIL

hydroflumethiazide Saluron

methyclothiazide Enduron

Thiazide-like diuretics chlorthalidone Hygroton

indapamide Lozol
 metolazone Mykrox, Zaroxolyn

bumetanide Bumex

ethacrynic acid Edecrin

Loop diuretics
furosemide Lasix

torsemide Demadex

acetazolamide Diamox

Carbonic Anhydrase Inhibitors

Glauctabs, MZM,
methazolamide
Neptazane

amiloride Midamor

Potassium-sparing Diuretics spironolactone Aldactone

triamterene Dyrenium

Osmotic Diuretics mannitol Osmitrol

 Thiazides and Thiazide-Like Diuretics

o Thiazide diuretics belong to a chemical class of drugs

called sulfonamides. Thiazide-like diuretics have different chemical
structure but work in the same mechanism as that of thiazide
diuretics.
o This is among the most commonly used class of diuretics.
o The first thiazide, chlorothiazide, was marketed in 1957 and was followed a year later by
hydrochlorothiazide.
o There are numerous thiazide and thiazide-like preparations
 Action
 o Thiazides are used to treat hypertension and peripheral edema.
o They are not effective for immediate diuresis and should not be used to promote
fluid loss in patients with severe renal dysfunction
o Thiazides cause a loss of sodium, potassium, and magnesium, but they promote
calcium reabsorption
 Indication

 Considered to be a milder form of diuretics compared to loop diuretics.

 First-line drugs for management of essential hypertension
Children

 Has established pediatric dosing guidelines used for the treatment of

edema in heart defects and hepatorenal diseases; control of hypertension
in children.
 Effect of diuretics may be abrupt in children because of their rapid
metabolism so caution is exercised by careful monitoring of serum
electrolyte changes and for evidence of fluid volume changes.
Adults

 Are more likely to use diuretics on long-term basis and should be

educated on warning signs of fluid volume changes that need prompt
medical attention.
 They should be instructed to weigh themselves daily to monitor for fluid
retention or sudden fluid loss.
 Conditions that may aggravate fluid loss like vomiting, diarrhea, and
profuse sweating should be emphasized to them because these may
change the need for diuretics.
Use of diuretics to influence fluid shifts in pregnant patients is not
appropriate. However, it should not be stopped if indicated for a specific
medical cause provided that they are made aware of the possible effects
to the fetus. Lactating women should switch to an alternative method of
feeding as this drug may have potential effect to the baby.
Older adults

 Have medical conditions where thiazide diuretics and thiazide-like

diuretics are usually indicated.
  The possibility of older adult patients having renal and hepatic
impairments requires health care team to be cautious of the use of this
drug.
 The lowest dose possible is started initially and it is titrated slowly
based on patient’s response.
 Frequent monitoring of serum electrolytes, activity level, and dietary
intake is a must.
o
 Nursing management
o Assessment
 Assess vital signs, weight, urine output, and serum chemistry values
(electrolytes, glucose, uric acid) for baseline levels.
 Check peripheral extremities for the presence of edema. Note pitting
edema.
 Obtain a history of drugs and herbal supplements taken daily.
 Review for drugs and herbs that may cause a drug interaction (digoxin,
corticosteroids, antidiabetics, ginkgo, licorice).

o Nursing Diagnoses
 Fluid Volume, Risk for Deficient
 Elimination, Impaired Urinary related to kidney dysfunction
 Fluid Volume, Excess related to body fluid retention
o Planning
 The patient’s blood pressure will be decreased or will return to a normal
value.
 The patient’s edema will be decreased.
 The patient’s serum chemistry levels will remain within normal ranges.
o Nursing Interventions
 Monitor vital signs and serum electrolytes, especially potassium, glucose,
uric acid, and cholesterol levels. Report changes. If a patient is taking
digoxin and hypokalemia occurs, digitalis toxicity frequently results.
 Observe for signs and symptoms of hypokalemia such as muscle
weakness, leg cramps, and cardiac dysrhythmias.
 Monitor the patient’s weight daily. A weight gain of 2.2 lb is equivalent
to 1 L of body fluids.
 Note urine output to determine fluid loss or retention.
o Evaluation
 Evaluate the effectiveness of drug therapy. The patient’s blood pressure
and edema will be reduced, and blood chemistry will remain within
normal range.
 Determine an absence of side effects and adverse reactions to therapy.
 Pharmacotherapeutic action
 o It causes active pumping out of chloride from the cells lining the
ascending limb of Loop of Henle and distal tubule by blocking the
chloride pump. Since sodium passively moves with chloride to
maintain electrical neutrality, both sodium and chloride are excreted
in the urine.

 Pharmacodynamic action
o Thiazides act directly on arterioles to cause vasodilation, which can lower blood
pressure.
o Other action includes the promotion of sodium chloride and water excretion,
resulting in a decrease in vascular fluid volume and a concomitant decrease in
cardiac output and blood pressure.
o The onset of action of hydrochlorothiazide occurs within 2 hours. Peak
concentration times are long (4 hours).
o Thiazides are divided into three groups according to their duration of action: (1)
short acting (duration 24 hours).
 Pharmacokinetics
o Thiazides are well absorbed from the gastrontestinal (GI) tract.
o Hydrochlorothiazide has moderate protein-binding power.
o The half-life of the thiazide drugs is longer than that of the loop diuretics.
o For this reason, thiazides should be administered in the morning to avoid nocturia
(nighttime urination) and sleep interruption.

 Contraindications/caution
o Allergy to loop diuretics. Prevent severe hypersensitivity reactions.

o Fluid and electrolyte imbalances. Can be potentiated by the changes

in fluid and electrolyte levels caused by diuretics.
o Severe renal failure, anuria. May prevent diuretics from working; can
precipitate crisis stage due to blood flow changes brought about by
diuretics.
o Systemic lupus erythematosus (SLE).  Can precipitate renal failure
because the disease already causes changes in glomerular filtration.
o Glucose tolerance abnormalities and diabetes mellitus. Worsened
by glucose-elevating effect of some diuretics
o Gout. Already reflects abnormality in tubular reabsorption and
secretion.
o Liver disease. Could interfere with drug metabolism and lead to drug
toxicity.
 o Bipolar disorder. Can be exacerbated by calcium changes brought
about by the use of this drug.
o Pregnancy, lactation. Can cause potential adverse effects to the fetus
and baby. Routine use of this drug in pregnancy is not appropriate and
should be used only when there is underlying pathological conditions.
For lactating women, an alternative method of feeding should be
instituted.
o
 Drug interactions
o Cholestyramine or colestipol: decreased absorption of diuretics; must
be taken separated by at least 2 hours.
o Digoxin: increased risk for digoxin toxicity because of changes in
serum potassium levels
o Quinidine: increased risk for quinidine toxicity

o Antidiabetic agents: decreased effectivity of antidiabetics

o Lithium: increased risk for lithium toxicity
o
 Side/adverse effects
o CNS: weakness
o CV: hypotension, arrhythmias

o GI: GI upset
o GU: hypokalemia (can precipitate hyperglycemia), hypercalcemia,
hyperuremia, slightly-alkalinized urine (can lead to bladder infections)

 Common drugs used in the market

Thiazide diuretics bendroflumethiazide Naturetin

chlorothiazide Diuril

hydrochlorothiazide HydroDIURIL

hydroflumethiazide Saluron
 methyclothiazide Enduron

chlorthalidone Hygroton

Thiazide-like diuretics indapamide Lozol

metolazone Mykrox, Zaroxolyn

 Loop (High-Ceiling) Diuretics

o This type of diuretics exerts its main effect on the loop of Henle.
Hence, so named.
o Referred to as high-ceiling diuretics because they are capable of
causing greater degree of diuresis compared to other types.
 Action
o Loop diuretics can affect blood glucose and can increase uric acid levels.
o This group of diuretics causes excretion of calcium, unlike thiazides, which
inhibit calcium loss.
o Loop diuretics can increase renal blood flow up to 40%
 Indication

o Indicated for treatment of acute HF, acute pulmonary edema, and

edema associated with HF or with renal or liver disease, and
hypertension.
o Drug of choice when rapid and extensive diuresis is needed. It can
produce a fluid loss up to 20 pounds per day.
o Proven to be effective even with the presence of acid-base
disturbances, renal failure, electrolyte imbalances, and nitrogen
retention.
o Also used in the treatment of pulmonary edema but its effect only
influences the blood that reaches the nephrons.
o Ethacrynic acid is used less frequently in the clinical setting because
newer drugs are more potent and reliable.
o Children

o Furosemide is used when a stronger diuretic is needed but dose

should not be more than 6 mg/kg/d.
o Ethacrynic acid is used in oral form in some situations but not in
infants.
o Bumetanide is generally not recommended for children but is
indicated when the child is taking other ototoxic drugs
(e.g. antibiotics). It causes less hypokalemia and makes it ideal for
children taking digoxin at the same time.
o Adults

o Are more likely to use diuretics on long-term basis and should be

educated on warning signs of fluid volume changes that need prompt
medical attention.
o They should be instructed to weigh themselves daily to monitor for
fluid retention or sudden fluid loss.
o Conditions that may aggravate fluid loss like vomiting, diarrhea, and
profuse sweating should be emphasized to them because these may
change the need for diuretics.
o Pregnant women

o Use of diuretics to influence fluid shifts in pregnant patients is not

appropriate. However, it should not be stopped if indicated for a
specific medical cause provided that they are made aware of the
possible effects to the fetus.
o Lactating women should switch to an alternative method of feeding as
this drug may have potential effect to the baby.
o Older adults

o Have medical conditions where thiazide diuretics and thiazide-like

diuretics are usually indicated.
o The possibility of older adult patients having renal and hepatic
impairments requires health care team to be cautious of the use of
this drug.
 o The lowest dose possible is started initially and it is titrated slowly
based on patient’s response.
o Frequent monitoring of serum electrolytes, activity level, and dietary
intake is a must.

 Nursing management
o Assessment
 Obtain a history of drugs taken daily. Note if the patient is taking a drug
that may interact with a loop diuretic, such as alcohol, aminoglycosides,
anticoagulants, corticosteroids, lithium, amphotericin B, or digitalis.
Recognize that furosemide is highly protein bound and can displace other
protein-bound drugs such as warfarin.
 Assess vital signs, serum electrolytes, weight, and urine output for
baseline levels.
 Compare the patient’s drug dose with the recommended dose, and report
any discrepancy.
 Note whether the patient is hypersensitive to sulfonamides. Nursing
o Diagnoses
 Fluid Volume, Risk for Deficient
 Electrolyte Imbalance, Risk for
o Planning
 The patient’s edema and/or hypertension will be decreased.
 The patient’s serum chemistry levels will remain within normal ranges.
o Nursing Interventions
 Monitor urinary output to determine body fluid gain or loss. Urinary
output should be at least 30 mL/h or 600 mL/24 h.
 Notify a health care provider if urine output does not increase; a severe
renal disorder may be present.
 Weigh the patient to determine fluid loss or gain. A loss of 2.2 lb is
equivalent to a fluid loss of 1 L.
 Monitor vital signs, and be alert for marked decreases in blood pressure. •
Administer IV furosemide slowly; hearing loss may occur if it is rapidly
injected.
 Observe for signs and symptoms of hypokalemia (Nursing Interventions
 Monitor urinary output to determine body fluid gain or loss. Urinary
output should be at least 30 mL/h or 600 mL/24 h.
 Notify a health care provider if urine output does not increase; a severe
renal disorder may be present.
 Weigh the patient to determine fluid loss or gain. A loss of 2.2 lb is
equivalent to a fluid loss of 1 L.
 Monitor vital signs, and be alert for marked decreases in blood pressure.
 Administer IV furosemide slowly; hearing loss may occur if it is rapidly
injected.
  Observe for signs and symptoms of hypokalemia (<3.5 mEq/L), such as
muscle weakness,abdominal distension, leg cramps, and/or cardiac
dysrhythmias.

 Monitor serum potassium levels, especially when a patient is taking

digoxin. Hypokalemia enhances the action of digitalis, causing digitalis
toxicity.

 Pharmacotherapeutic action
o Blocks the action of chloride pump in the ascending limb of the loop of
Henle, where 30% of sodium is normally reabsorbed. This causes
decreased reabsorption of chloride and sodium.
o Exerts the same effect on the descending limb of loop of Henle and
distal tubule causing sodium-rich urine.
o
 Pharmacodynamic action
o Loop diuretics have a great saluretic (sodium chloride–losing) or natriuretic
(sodium-losing) effect and can cause rapid diuresis, decreasing vascular fluid
volume and causing a decrease in cardiac output and blood pressure.
o Because furosemide is more potent than thiazide diuretics, it causes a vasodilatory
effect; thus renal blood flow increases before diuresis.
o Furosemide is used when other conservative measures, such as sodium restriction
and use of less potent diuretics, fail.
o The oral dose of furosemide is usually twice that of an intravenous (IV) dose.
o The onset of action of loop diuretics occurs within 30 to 60 minutes. The onset of
action for IV furosemide is 5 minutes.
o The duration of action is shorter than that of the thiazides
 Pharmacokinetics
o Loop diuretics are rapidly absorbed by the GI tract.
o These drugs are highly protein bound with halflives that vary from 1 to 5 hours.
o Loop diuretics compete for protein-binding sites with other highly protein-bound
drugs.
 Contraindications/caution
o Allergy to thiazides and sulfonamides. Prevent severe
hypersensitivity reactions.
o Electrolyte depletion. Can be potentiated by the changes in fluid and
electrolyte levels caused by diuretics.
o Severe renal failure, anuria. Exacerbated by the effects of the drug.
 o Systemic lupus erythematosus (SLE).  Can precipitate renal failure
because the disease already causes changes in glomerular filtration.
o Glucose tolerance abnormalities and diabetes mellitus. Worsened
by glucose-elevating effect of some diuretics
o Gout. Already reflects abnormality in tubular reabsorption and
secretion.
o Hepatic coma. Exacerbated by fluid shifts associated with drug use.
o Pregnancy, lactation. Can cause potential adverse effects to the fetus
and baby. Routine use of this drug in pregnancy is not appropriate and
should be used only when there is underlying pathological conditions.
For lactating women, an alternative method of feeding should be
instituted.

 Drug interactions
o Aminoglycosides or cisplatin: increased ototoxicity effect of loop
diuretics
o Anticoagulants: increased anticoagulation effects

o Indomethacin, ibuprofen, salicylates and other NSAIDs: decreased

antihypertensive effects and loss of sodium
o
 Side/adverse effects
o CNS: dizziness
o CV: hypotension

o GI: GI upset
o GU: hypokalemia (can precipitate hyperglycemia), increased
bicarbonate excretion (can lead to alkalosis), hypocalcemia and tetany
o EENT: ototoxicity, reversible loss of hearing
 Common drugs used in the market

Loop diuretics

ethacrynic acid Edecrin

furosemide Lasix
 torsemide Demadex

 Osmotic Diuretics
o This type of diuretic exerts their therapeutic effect by pulling water
into the renal tubule without loss of sodium.
o Only one osmotic diuretic is currently available, mannitol (Osmitrol).
 Action
o Osmotic diuretics increase the osmolality (concentration) and sodium
reabsorption in the proximal tubule and loop of Henle
o This group of drugs is used to prevent kidney failure, decrease intracranial
pressure (ICP, such as in cerebral edema), and decrease intraocular pressure (IOP,
such as in glaucoma
 Indication

o Mannitol is usually used in acute situations when it is necessary to

decrease IOP before eye surgery or during acute attacks of glaucoma.
o Diuretic of choice in cases of increased cranial pressure or acute renal
failure due to shock, drug overdose, or trauma.
o Also available as an irrigant in transurethral prostatic resection and
other transurethral procedures.
Children
 o Not indicated for children
Adults

o Conditions that may aggravate fluid loss like vomiting, diarrhea, and
profuse sweating should be emphasized to them because these may
change the need for diuretics.
Pregnant women

o Use of diuretics to influence fluid shifts in pregnant patients is not

appropriate. However, it should not be stopped if indicated for a
specific medical cause provided that they are made aware of the
possible effects to the fetus.
o Lactating women should switch to an alternative method of feeding as
this drug may have potential effect to the baby.
Older adults

o Have medical conditions where thiazide diuretics and thiazide-like

diuretics are usually indicated.
o The possibility of older adult patients having renal and hepatic
impairments requires health care team to be cautious of the use of
this drug.
o The lowest dose possible is started initially and it is titrated slowly
based on patient’s response. Frequent monitoring of serum
electrolytes, activity level, and dietary intake is a must.

 Nursing management
o
 Pharmacotherapeutic action
o Mannitol is a sugar that is not well reabsorbed by the tubules and it
acts to pull large amounts of fluid into the urine due to the osmotic
pull exerted by large sugar molecule.
o This also pulls fluid into the vascular system from extravascular spaces
like aqueous humor.

 Pharmacodynamic action

 Pharmacokinetics
Route Onset Peak Duration
IV 30-60 min 1h 6-8 h

Irrigant Rapid Rapid Short

T1/2:  15-100 min

Metabolism: N/A
Excretion: urine (unchanged)

o
 Contraindications/caution
o Renal disease, anuria, pulmonary congestion,
intracranial bleeding, dehydration, HF. Exacerbated by large shifts
in fluid related to drug use.
o Pregnancy, lactation. Can cause potential adverse effects to the fetus
and baby. Routine use of this drug in pregnancy is not appropriate and
should be used only when there is underlying pathological conditions.
For lactating women, an alternative method of feeding should be
instituted.
o
 Drug interactions
 Side/adverse effects
o CNS: light-headedness, confusion, headache

o CV: hypotension, cardiac decompensation, shock

o GI: nausea, vomiting
o GU: fluid and electrolyte imbalance
o Most common and potentially dangerous adverse effect related to an
osmotic diuretic is the sudden drop in fluid levels.
o
 Common drugs used in the market

Osmotic Diuretics mannitol Osmitrol

  Carbonic Anhydrase Inhibitors
o This group of drugs is used primarily to decrease IOP in patients with open-angle
(chronic) glaucoma. These drugs are not used in narrow-angle or acute glaucoma
o . Other uses include diuresis, management of epilepsy, and treatment of high-altitude or
acute mountain sickness.
o Relatively mild diuretics.

 Action
o The carbonic anhydrase inhibitors acetazolamide and methazolamide block the
action of the enzyme carbonic anhydrase, which is needed to maintain the body’s
acid-base balance (hydrogen and bicarbonate ion balance).
o Inhibition of this enzyme causes increased sodium, potassium, and bicarbonate
excretion.
o With prolonged use, metabolic acidosis can occur.
 Indication

 Most often used for the treatment of glaucoma. Inhibition of carbonic

anhydrase results in decreased secretion of aqueous humor of the eyes.
 Also used as adjunct to other diuretics when more intense diuresis is
needed.
Children

 Not indicated for children

Adults

 Are more likely to use diuretics on long-term basis and should be

educated on warning signs of fluid volume changes that need prompt
medical attention.
 They should be instructed to weigh themselves daily to monitor for fluid
retention or sudden fluid loss.
Conditions that may aggravate fluid loss like vomiting, diarrhea, and

profuse sweating should be emphasized to them because these may
change the need for diuretics.
Pregnant women

 Use of diuretics to influence fluid shifts in pregnant patients is not

appropriate. However, it should not be stopped if indicated for a specific
 medical cause provided that they are made aware of the possible effects
to the fetus.
Lactating women should switch to an alternative method of feeding as this

drug may have potential effect to the baby.
Older adults 

 Have medical conditions where thiazide diuretics and thiazide-like

diuretics are usually indicated.
 The possibility of older adult patients having renal and hepatic
impairments requires health care team to be cautious of the use of this
drug.
 The lowest dose possible is started initially and it is titrated slowly based
on patient’s response.
 Frequent monitoring of serum electrolytes, activity level, and dietary
intake is a must.
o
 Nursing management
 Pharmacotherapeutic action
o Inhibits the action of the enzyme carbonic anhydrase, the catalyst for
the formation of sodium bicarbonate stored as alkaline reserve in the
renal tubules and is important for the excretion of hydrogen.
o It slows down the movement of hydrogen ions which leads to greater
amount of sodium and bicarbonate lost in the urine.
o
 Pharmacodynamic action
o
 Pharmacokinetics
Route Onset Peak Duration

Oral 1h 2-4 h 6-12 h

Sustained-release oral 2h 8-12 h 18-24 h

IV 1-2 min 15-18 min 4-5 h

T1/2:  5-6 h
Metabolism: N/A
Excretion: urine (unchanged)

o
 Contraindications/caution
o Allergy to carbonic anhydrase inhibitors, thiazides, antibacterial
sulfonamides. Prevent severe hypersensitivity reactions.
o Chronic noncongestive angle-closure glaucoma. Not effectively
treated by this drug.
o Fluid and electrolyte imbalance, renal or hepatic disease,
adrenocortical insufficiency, respiratory acidosis, chronic
obstructive pulmonary disease (COPD). Could be exacerbated by
fluid and electrolyte changes caused by these drugs.
o Pregnancy, lactation. Can cause potential adverse effects to the fetus
and baby. Routine use of this drug in pregnancy is not appropriate and
should be used only when there is underlying pathological conditions.
For lactating women, an alternative method of feeding should be
instituted.

 Drug interactions
o Salicylate, lithium: increased excretion of these drugs
 Side/adverse effects
o CNS: paresthesia, confusion, drowsiness

o CV: hypotension
o GU: hypokalemia (can precipitate hyperglycemia), increased loss of
bicarbonate (can lead to metabolic acidosis)
o
 Common drugs used in the market

acetazolamide Diamox
Carbonic Anhydrase Inhibitors
methazolamide Glauctabs, MZM, Neptazane
  Potassium-Sparing Diuretics

o Less powerful than loop diuretics but they retain potassium instead of
wasting it.
o Typically used for patients who have high risk for hypokalemia
associated with diuretic use.
 Action
o Potassium-sparing diuretics act primarily in the collecting duct renal tubules and
late distal tubule to promote sodium and water excretion and potassium retention.
o The drugs interfere with the sodium-potassium pump controlled by the
mineralocorticoid hormone aldosterone (sodium retained and potassium excreted).
 Indication

 This is often used as adjuncts with thiazide or loop diuretics or in patients

who are especially at risk if hypokalemia develops.
Spironolactone is the drug of choice for
treating hyperaldosteronism typically seen in patients with liver cirrhosis
and nephrotic syndrome.
Children 

 Spironolactone is the only potassium-sparing diuretic recommended for

children.
Adults

Instruct to avoid potassium-rich foods (e.g. avocados, bananas, broccoli,


tomatoes, and dried fruits) and to have regular monitoring of serum
potassium levels.
Pregnant Women

 Use of diuretics to influence fluid shifts in pregnant patients is not

appropriate. However, it should not be stopped if indicated for a specific
medical cause provided that they are made aware of the possible effects
to the fetus.
 Lactating women should switch to an alternative method of feeding as this
drug may have potential effect to the baby.
Older adults

 Have medical conditions where thiazide diuretics and thiazide-like

diuretics are usually indicated.
 The possibility of older adult patients having renal and hepatic
impairments requires health care team to be cautious of the use of this
drug.
 The lowest dose possible is started initially and it is titrated slowly based
on patient’s response. Frequent monitoring of serum electrolytes, activity
level, and dietary intake is a must.

 Nursing management
o Assessment •
 Obtain a history of drugs taken daily. Note whether the patient is taking a
potassium supplement or using a salt substitute.
 Assess vital signs, serum electrolytes, weight, and urinary output for
baseline levels.
 Compare the patient’s drug dose with the recommended dose, and report
any discrepancy.
o Nursing Diagnoses
 Fluid Volume, Risk for Deficient
 Electrolyte Imbalance, Risk for
o Planning
 The patient’s fluid retention and blood pressure will be decreased.
 The patient’s serum electrolytes will remain within normal ranges.
o Nursing Interventions
 Note the half-life of spironolactone. With a long half-life, the drug is
usually administered once a day, sometimes twice a day.
 Monitor urinary output; it should increase. Report if urine output is less
than 30 mL/h or less than 600 mL/day.
 Record vital signs and report any abnormal changes.
 Observe for signs and symptoms of hyperkalemia (serum potassium >5.0
mEq/L). Nausea, diarrhea, abdominal cramps, numbness and tingling of
the hands and feet, leg cramps, tachycardia and later bradycardia, peaked
narrow T wave on electrocardiogram, or oliguria may signal
hyperkalemia.
 Administer spironolactone in the morning and not in the evening to avoid
nocturia.
o Evaluation
  Evaluate the effectiveness of potassium-sparing diuretics (e.g.,
triamterene). Fluid retention (edema) should be decreased or absent.
 Determine whether urine output has increased and whether serum
potassium level is within the normal range
 Pharmacotherapeutic action
o This type of diuretics causes a loss of sodium while promoting the
retention of potassium.
o Spironolactone acts as aldosterone antagonist which blocks the
action of aldosterone in the distal tubule. On the other
hand, amiloride and triamterene block potassium secretion through
the tubule.
o
 Pharmacodynamic action
 Pharmacokinetics
Route Onset Peak Duration

Oral 24-48 h 48-72 h 48-72 h

T1/2:  20 h
Metabolism: liver
Excretion: urine (unchanged)

o
 Contraindications/caution
o Allergy to potassium-sparing diuretics. Prevent severe
hypersensitivity reactions.
o Hyperkalemia, renal disease, anuria. Exacerbated by the effects of
the drug.
o Pregnancy, lactation. Can cause potential adverse effects to the fetus
and baby. Routine use of this drug in pregnancy is not appropriate and
should be used only when there is underlying pathological conditions.
For lactating women, an alternative method of feeding should be
instituted.

 Drug interactions
o Salicylates: decreased diuretic effect
o
 Side/adverse effects
o CNS: lethargy, confusion, ataxia
 o CV: arrhythmias
o Musculoskeletal: muscle cramps
o GU: hyperkalemia, increased loss of bicarbonate (can lead to metabolic
acidosis)
o Associated with various androgen effects such as hirsutism,
gynecomastia, deepening of the voice, and irregular menses.

 Common drugs used in the market

amiloride Midamor

Potassium-sparing Diuretics spironolactone Aldactone

triamterene Dyrenium