DIURETICS

TOYA ARIAWAN
 Definition :
are drugs that elevates the rate
of bodily urine excretion
(diuresis).

CLASSIFICATION

* LOOP DIURETICS
* THIAZIDES DIURETICS
* POTASSIUM - SPARING DIURETICS
* OSMOTIC DIURETICS
* CARBONIC ANHYDRASE INHIBITORS
IN INCREASING URINE PRODUCTION

Most diuretics initially inhibit sodium reabsorption followed by

water reabsorption inhibition

EXCEPT

osmotic diuretics initially inhibit water reabsorption followed by

sodium reabsoprtion inhibition

Most of them act from the luminal side of the tubules membrane
(filtered at glomerulus & some secreted in the proximal tubule) and
must be present in the urine except the aldosterone receptor
antagonists
 65% 4-8%

15-
25%

2-5%

Carbonic anydrase
inhibitor

Potassium- sparing
diuretics
 Carbon Carbonic
ic anhydrase
anhydr inhibitors
ase
Acetazolamide
inhibito
rs
CA= carbonic
anhydrase
 Loop
diuretics

Furosemide
Bumetanide
Torsemide
Ethacrynic
acid
Thiazide
diuretics

Hydrochlorothiaz
ide
Chlorthalidone
Indapamide
Metolazone
 Potassium 2
sparing
diuretics 1

1. Aldosterone
antagonist

spironolacto
ne,
eplerenon
2. Blocking Na
 Osmotic
diuretics

Osmotic
diuretics

Mannitol
 WHY LOOP DIURETICS
SO POTENT AS
DIURETICS?
Inhibition Na+/K+/2CL-
transporter in the
medullary parts of the
thick ascending limb of
Henle by furosemide
eliminate the
hyperosmotic condition of
the renal medulla
water reabsorption in
the collecting tubule
under the influenced
CLINICAL USES
- edematous states (e.g. heart failure,
ascites, nephrotic
syndrome)
- hypertension
CLINICAL USES
- edema (heart failure,
Others
cirrhosis hepatis,
kidney diseases)
- glaucoma
- hypertension

- prevent acute mountain (high

altitude) sickness
- reducing intracranial pressure
- severe hypercalcemia
- recurrent renal calcium stone
formation
EFFICACY OF DIURETICS

Loop diuretics > thiazid diuretics >

potassium-sparing diuretics

Often combine
loop diuretics + potassium-sparing
diuretics
thiazide diuretics + potassium-sparing
diuretics
 DIURETICS IN HYPERTENSION
THIAZIDE DIURETICS
(hydrochlorothiazide, indapamide ,
2007 chlorthalidone)

ESC most frequently used in

LOOP DIURETICS
hypertension
and (furosemide)
ESH heart failure
Guid end stage renal disease
e- ALDOSTERONE ANTAGONIST

lines (spironolactone, eplerenone)

heart failure
post myocardial infarction
 *SNS **RAAS

Diuretics
Venous
Peripheral
resistance tone

Blood
Venous
pressure Stroke
volume return

Cardiac Blood
output volume

Cardiac Diuretics
*SNS =sympathetic Heart rate contractility
nervous system
**RAAS = renin
angiotensin
 THIAZIDES IN NEPHROGENIC
DIABETES INCIPIDUS (NDI)

Renal sodium loss

Extracelllular
ANTIDIURETIC volume contraction
ACTION OF Lowered GFR &
THIAZIDES IN increased proximal
NDI IS
tubular sodium &
SECONDARY water absorption
TO
INCREASED IN
Less water and
solutes are delivered
RENAL
SODIUM to distal tubule and
EXCRETION
collecting tubule

Less urine loss

HYPOKALEMIA
(loop diuretics, thiazide
diuretics)
The presentation of large
amounts of sodium to the cortical
collecting tubule may results in
potassium wasting because some
of the excess sodium is
reabsorbed and potassium is
HYPERKALEMIA
secreted
(potassium -sparing diuretics)
The inhibition of sodium
reabsorption in cortical collecting
tubule may results in retention of
potassium
Combination potassium-sparing diuretics with ACE inhibitor
(captopril) or ARB (losartan) causing severe hyperkalemia
CALCIUM IN THE URINE

HYPERCALCIURIA
(loop diuretics)

HYPOCALCIURIA
(thiazide diuretic)
Metabolic acidosis:
excretion of bicarbonate ( carbonic anhydrase
inhibitors)
excretion of hydrogen ion ( K+ sparing
diuretics)
Metabolic alkalosis
excretion of hydrogen ion (loop diuretics &
thiazides)
 TASK
1. What kind diuretics used in these
conditions ?
- glaucoma
- prevent acute mountain (high altitude)
sickness
- reducing intracranial pressure
- severe hypercalcemia
- recurrent renal calcium stone
formation
- nephrogenic diabetes incipidus
2. Explain what diuretic has gynecomastia
side effect
ADH AGONISTS
& ANTAGONIST
Osmotic
diuretics
ADH AGONIST
ADH &
Desmopressin
Stimulate V2
receptor in the
collecting tubule
Pituitary
Cyclic AMP
diabetes
Insertion additional incipidus
AQP2 water Side effect:
channel in the Hyponatremia
luminal membrane Hypertension
Facilitate water
reabsorption
ADH ANTAGONIST
Conivaptan & Tolvaptan

Syndrome of in appropriate ADH secretion

(SIADH) (significant water retention &
hyponatremia) caused by small cell Ca of
the lung

Side effect:
Serious neurologic consequence

Demeclocycline also effective for

this cases
SE : bone & teeth
THANK
YOU