DIURETICS & MINERALOCORTICOIDS

DIURETICS
Thiazides
I. Hydrochlorothiazide
Chemical Name: Hydrochlorothiazide
Trade Name: Hydrazide, Aquazide
Dosage:
Adults: 25 -100 mg /day
Children: 2mg/kg/day in divided doses
Half Life: 5-15 hrs
Route of Administration: PO
Indication: Edema, hypertension, Diuresis, CHF
Mechanism of Action: Acts on Distal tubule and Ascending limb of LOH by increasing excretion
of water, sodium, potassium and Chloride.
Side Effects: Urinary frequency, uremia, glycosuria, dizziness, hepatitis, GI irritation, Blurred
vision, hyperglycemia, hyper uricemia, anaemia, leukopenia, thrombocytopenia,
Orthostatic hypertension, hypokalemia, hyponatremia
Precautions: hypokalemia, renal disease, pregnancy and lactation, hepatic disease, hyperlipidemia
Contraindications: Hypersensitivity to sulphonamides, anuria, renal decompensation,
hypomagnesemia.

II. Metolazone
Chemical Name: Metolazone
Trade Name: Zytanix, Metoz, Zaroxolyn, and Mykrox
Dosage:
Adults: 2.5-10 mg PO once daily, increased to 20 mg once daily.
Children: 0.2-0.4 mg/kg/day PO in single daily dose or divided q12hr.
Half Life: 6-8 hrs
Route of Administration: PO
Indication: Edema, hypertension
Mechanism of Action: Inhibits reabsorption of sodium in distal tubules, causing increased
excretion of water and of sodium, potassium, and hydrogen ions
Side Effects: Electrolyte abnormalities, Headache, Hepatotoxicity, Orthostatic hypotension,
Stevens-Johnson syndrome, Syncope, Volume depletion
Precautions: diabetes mellitus, hypercholesterolemia, hyperuricemia or gout, hypotension,
systemic lupus erythematosus (can cause exacerbation or activation), liver disease.
Avoid concurrent use with lithium.
May aggravate digitalis toxicity
Pregnancy (Cross placenta) and lactation (excreted in breast milk).
Contraindications: hypersensitivity to metolazone or sulfonamides, Anuria, Hepatic coma or
precoma

Loop Diuretics
I. Furosemide
Chemical Name: Furosemide
Trade Name: Lasix, Furoscix
Dosage:
Adults:
Edema: 20-80 mg PO once daily, may be increased by 20-40 mg q6-8hr, not to exceed 600 mg/day
Hypertension, Resistant: 20-80 mg PO divided q12hr
Acute Pulmonary Edema/Hypertensive Crisis/Increased Intracranial Pressure: 0.5-1 mg/kg
(or 40 mg) IV over 1-2 minutes, may be increased to 80 mg if there is no adequate response within
1 hour, not to exceed 160-200 mg/dose
Injectable solution (SC; Furoscix): 80mg/10mL single-dose prefilled cartridge for on-body
infusor
Pediatric:
Edema: infants and children: 1-2 mg/kg IV/IM/PO once initially; increased by 1-2 mg/kg q6-8hr
(PO) or 1 mg/kg q2hr (IV/IM); individual dose not to exceed 6 mg/kg
Neonates (<28 days): 0.5-1 mg/kg IV/IM q8-24hr; individual dose not to exceed 2 mg/kg
Half Life: 30-120 min (normal renal function); 9 hr (end-stage renal disease)
Route of Administration: IV/IM/PO/SC
Indication: Edema, hypertension, Acute Pulmonary Edema, Hypertensive Crisis, Increased
Intracranial Pressure
Mechanism of Action: Loop diuretic; inhibits reabsorption of sodium and chloride ions at
proximal and distal renal tubules and loop of Henle
Side Effects: Hyperuricemia, Hypokalemia, Hearing impairment, Tinnitus, Hypotension
Increased patent ductus arteriosus during neonatal period, Muscle cramps
Precautions: hypersensitivity to furosemide or sulfonamides, Anuria, Hepatic cirrhosis or ascites
Contraindications: hypersensitivity to furosemide or sulfonamides, Anuria, Hepatic cirrhosis or
ascites

II. Torsemide
Chemical Name: Torsemide
Trade Name: Dytor, Tide
Dosage:
Adults:
Edema: 10-20 mg PO daily initially; may increase dose by doubling until desired diuretic effect
is achieved
Hepatic Cirrhosis: 5-10 mg PO daily initially, may increase dose by doubling until desired
diuretic effect achieved
Hypertension: 2.5-5 mg/day PO initially; increased to 10 mg/day PO in 4-6 weeks PRN
Children: safety and efficacy not established
Half Life: 6-8 hrs
Route of Administration: PO
Indication: Edema, hypertension, Hepatic cirrhosis
Mechanism of Action: acting at Na-K-2Cl reabsorptive pump at ascending loop of Henle;
interferes with chloride-binding cotransport system, causing increased excretion of water, sodium,
chlorine, magnesium, and calcium
Side Effects: Headache, Electrolyte imbalance, Dizziness, Constipation, Cough, Dyspepsia
Precautions: Diabetes mellitus, fluid or electrolyte imbalance (hypokalemia, hyponatremia),
hyperglycemia, hyperlipidemia, hyperuricemia or gout, severe liver disease with cirrhosis and
ascites
Contraindications: Hypersensitivity to torsemide or to povidone, Anuria, Hepatic coma

Carbonic anhydrase inhibitors

I. Acetazolamide
Chemical Name: Acetazolamide
Trade Name: Diamox
Dosage:
Adults:
CHF-associated edema: 250-375 mg (5 mg/kg) PO qAM
Drug-induced Edema: 250-375 mg PO/IV OD
Half Life: 2-4 hr
Route of Administration: PO/IV
Indication: Edema, hypertension, Diuresis, CHF
Mechanism of Action: Inhibits H+ ion excretion in renal tubule, increasing sodium, potassium,
bicarbonate, and water excretion and producing alkaline diuresis
Side Effects: Drowsiness, Paresthesia, Metallic taste, Hepatic disease, Electrolyte imbalance,
Muscle weakness, Hematuria, Hearing dysfunction or tinnitus
Precautions: COPD, emphysema, and concomitant high-dose aspirin
Contraindications: Hypokalemia, Hyponatremia, Hypersensitivity, Liver disease, Severe renal
disease or dysfunction

Potassium Sparing Diuretics

I. Spironolactone
Chemical Name: Spironolactone
Trade Name: Aldactone, Seolactone
Dosage:
Adults:
Essential Hypertension: 25-100mg PO OD or divided q12hr initially
Congestive Heart Failure: NYHA Class III-IV heart failure and reduced ejection fraction:
25mg/day PO may increase to 50 mg/day
Hypokalemia: 25-100 mg PO OD
Pediatrics: 1-3.3 mg/kg/day PO or divided q12hr
Half Life: 1.3-1.4 hr
Route of Administration: PO
Indication: Edema, hypertension, CHF, Hypokalemia
Mechanism of Action: Competitive binding of receptors at aldosterone-dependent Na-K
exchange site in distal tubules results in increased excretion of Na+, Cl-, and water and retention
of K+ and H+
Side Effects: Hyperkalemia, GU bleeding, gastritis, Agranulocytosis.
Precautions: Tumorigenic in chronic toxicity, use only for specified indications.
Contraindications: Hypersensitivity, Addison disease or other conditions associated with
hyperkalemia
Coadministration with eplerenone

Osmotic Diuretics
I. Mannitol
Chemical Name: Mannitol
Trade Name: Osmitrol, Pearlitrol
Dosage:
Adults:
Elevated ICP: 1.25 g/kg IV infused over 30-60 minutes; may repeat q6-8hr
Elevated IOP: 1.5-2 g/kg IV infused over 30-60 minutes
Pediatrics:
Elevated ICP: 0.25-1 g/kg IV initially; maintenance dose of 0.25-0.5 g/kg IV q4-6hr
Elevated IOP: 1.5-2 g/kg of a 20% solution (7.5-10 mL/kg) as single dose infused IV over 30-60
minutes
Half Life: 100 min
Route of Administration: IV
Indication: Elevated ICP, IOP
Mechanism of Action: hinders tubular reabsorption of water and enhances excretion of sodium
and chloride by elevating the osmolarity of the glomerular filtrate
Side Effects: Hypersensitivity, Renal failure, CNS toxicity, Fluid and electrolyte imbalance.
Precautions: administer in large vein, do not mix with blood.
Contraindications: Hypersensitivity, Anuria, Severe hypovolemia, Pre-existing severe
pulmonary vascular congestion or pulmonary edema, Active intracranial bleeding, except during
craniotomy
Nurses’ Responsibility: Diuretics
Assess:
• Weight and I/O chart
• Blood pressure monitoring
• Serum electrolytes
• Signs of metabolic acidosis or hypokalemia.
• Torsemide – bleeding manifestations
Administer:
• In AM to avoid interference with sleep
• Potassium replacement
• With food or milk to decrease GI symptoms.
• Torsemide – Antacid before oral agent, give after evening meal, before bed time.
• Mannitol – administer solution with filter
• Mannitol – caution with CHF, as rapid infusion may worsen CHF.
Teach:
• Increase fluid intake if not contraindicated
• To rise slowly from lying to sitting position.
• Notify if any muscle weakness or cramps.
• Drug to be taken with food or milk.
• Use sunscreen for photosensitivity
• Furosemide – need for high potassium diet
• Torsemide – storage in light resistant container at room temperature.
• Acetazolamide – store in dark, cool area, use reconstituted solution within 24 hours.
• Spironolactone – Avoid food with high potassium
MINERALOCORTICOIDS
I. Fludrocortisone
Chemical Name: Fludrocortisone
Trade Name: Florinef
Dosage:
Adults:
Adrenocortical Insufficiency/Addison Disease
0.1 mg/day PO
0.1 mg PO 3 times weekly to 0.2 mg/day PO
If hypertension occurs: 0.05 mg/day PO
Severe Orthostatic Hypotension
0.1 mg/day PO
Half Life: 3.5 hr
Route of Administration: PO
Indication: Adrenocortical Insufficiency/Addison Disease Severe Orthostatic Hypotension
Mechanism of Action: promotes increased reabsorption of sodium and excretion of potassium
from renal distal tubules.
Side Effects: Adrenal suppression, Delayed wound healing, Diabetes mellitus, Glucose
intolerance, Hepatomegaly, Osteoporosis, Peptic ulcer, Perianal pruritus, Weight gain.
Precautions: diabetes mellitus, hypertension, hypothyroidism, electrolyte abnormalities,
infections, immunizations, myasthenia gravis, peptic ulcer disease, renal insufficiency.
Contraindications: Systemic fungal infection, Hypersensitivity, Receipt of live or attenuated live
vaccine

II. Eplerenone
Chemical Name: Eplerenone
Trade Name: Inspra
Dosage:
Hypertension
Initial 50 mg PO OD; may increase to 50 mg PO q12hr
Heart Failure Post MI
Initial 25 mg PO OD; may titrate to maximum of 50 mg once daily within 4 weeks as tolerated
Half Life: 3.5-6 hr
Route of Administration: PO
Indication: Hypertension, Heart Failure
Mechanism of Action: Selective aldosterone receptor antagonist; blocks aldosterone binding at
the mineralocorticoid receptor
Side Effects: Increased risk of hyperkalemia with presence of renal dysfunction
Precautions: Hyperkalemia, liver dysfunction, metabolic or respiratory acidosis, renal
impairment, hypersensitivity to spironolactone
Contraindications: Hypersensitivity
Nurses’ Responsibility:
Assess:
• Weight and I/O chart
• Blood pressure monitoring
• Serum electrolytes – potassium depletion.
• Signs of metabolic acidosis or hypokalemia.

Administer:
• Administer in titrated dose, use lowest effective dose.
• in combination with high salt diet and adequate fluid intake
• Potassium replacement
• With food or milk to decrease GI symptoms.
• Assist with ambulation in patients with bone diseases to prevent fractures.
Teach:
• Carry ID as steroid user.
• Do not discontinue medication abruptly.to notify, if any muscle cramps or weakness.

Prepared by
Indira V R