Renal Pharmacology Drugs affecting the Kidney

Drug classification The nursing process applied to pharmacology Pharmacokinetics Pharmacodynamics

Outline of review Recall the anatomy of the urinary system Recall the physiology of the urinary system Review- drugs of the following categories: 1. Diuretics 2. Drug for BPH

Recall the anatomy of the urinary system

Recall the physiology of the urinary system

Review- drugs of the following categories:

1. Diuretics

2. Drug for BPH

Diuretics Agents that increase the amount of urine produced by the kidneys

Agents that increase the amount of urine produced by the kidneys

Classes of Diuretics Five major classes 1. Thiazides and thiazide-like 2. Loop diuretics 3. Potassium-sparing 4. Carbonic anhydrase inhibitors 5. Osmotic diuretics

Five major classes

1. Thiazides and thiazide-like

2. Loop diuretics

3. Potassium-sparing

4. Carbonic anhydrase inhibitors

5. Osmotic diuretics

General indications for the use of the diuretics Treatment of edema Urine output will increase and excess fluid is flushed out of the body

Treatment of edema

Urine output will increase and excess fluid is flushed out of the body

General indications for the use of the diuretics Treatment of CHF The sodium loss in the kidney is associated with water loss

Treatment of CHF

The sodium loss in the kidney is associated with water loss

General indications for the use of the diuretics Treatment of Hypertension Diuretics will decrease the blood volume and serum sodium

Treatment of Hypertension

Diuretics will decrease the blood volume and serum sodium

General indications for the use of the diuretics Treatment of Glaucoma Diuretics will provide osmotic pull to remove some of the fluid from the eye to decrease the IOP

Treatment of Glaucoma

Diuretics will provide osmotic pull to remove some of the fluid from the eye to decrease the IOP

time of administration of the diuretics Usually in the morning!!

Usually in the morning!!

Diuretics Comparison Hypokalemia Ototoxicity Loop of Henle 3. Loop diuretics Hypovolemia & hypotension Glomerulus 5. Osmotic diuretic Hyperkalemia Distal tubule 4. Potassium sparing Hyperuricemia Hypokalemia Proximal tubule 2. Thiazide and thiazide like Acidosis Proximal tubule 1. Carbonic anhydrase inhibitor Special Side effect (s) Major site of action Diuretic class

Diuretics Comparison Hypercalcemia 3. Loop diuretics Increased ICP LITHIUM TOXICITY 5. Osmotic diuretic CHF taking digoxin 4. Potassium sparing Nephrolithiasis due to calcium stones Hypocalcemia 2. Thiazide and thiazide like Mountain sickness Meniere’s disease 1. Carbonic anhydrase inhibitor Special Uses Diuretic class

Thiazides Prototype: Hydrochloro thiazide 1. Bendroflume thiazide 2. Ben thiazide 3. Chloro thiazide (Diuril) 4. Hydroflume thiazide 5. Methylclo thiazide 6. Trichlorme thiazide

Prototype: Hydrochloro thiazide

1. Bendroflume thiazide

2. Ben thiazide

3. Chloro thiazide (Diuril)

4. Hydroflume thiazide

5. Methylclo thiazide

6. Trichlorme thiazide

Thiazide-like 1. Indapamide 2. Quinethazone 3. Metolazone 4. Chlorthalidone

1. Indapamide

2. Quinethazone

3. Metolazone

4. Chlorthalidone

Thiazides Pharmacodynamics These drugs BLOCK the chloride pump This will keep the Chloride and Sodium in the distal tubule to be excreted into the urine Potassium is also flushed out!!

Pharmacodynamics

These drugs BLOCK the chloride pump

This will keep the Chloride and Sodium in the distal tubule to be excreted into the urine

Potassium is also

flushed out!!

Thiazide Special Pharmacodynamics: Side effects Hypokalemia DECREASED calcium excretion  hypercalcemia DECREASED uric acid secretion  hyperuricemia Hyperglycemia

Special Pharmacodynamics: Side effects

Hypokalemia

DECREASED calcium excretion  hypercalcemia

DECREASED uric acid secretion  hyperuricemia

Hyperglycemia

Loop Diuretics Prototype: Furosemide 1. Bumetanide 2. Ethacrynic acid 3. Torsemide

Prototype: Furosemide

1. Bumetanide

2. Ethacrynic acid

3. Torsemide

Loop Diuretics Pharmacodynamics High-ceiling diuretics BLOCK the chloride pump in the ascending loop of Henle SODIUM and CHLORIDE reabsorption is prevented Potassium is also excreted together with Na and Cl

Pharmacodynamics

High-ceiling diuretics

BLOCK the chloride pump in the ascending loop of Henle

SODIUM and CHLORIDE reabsorption is prevented

Potassium is also excreted together with Na and Cl

Loop Diuretics

Loop Diuretics Special Pharmacodynamics: side-effects Hypokalemia Bicarbonate is lost in the urine INCREASED calcium excretion  Hypocalcemia Ototoxicity- due to the electrolyte imbalances

Special Pharmacodynamics: side-effects

Hypokalemia

Bicarbonate is lost in the urine

INCREASED calcium excretion  Hypocalcemia

Ototoxicity- due to the electrolyte imbalances

Potassium sparing diuretics Prototype: Spironolactone 1. Amiloride 2. Triamterene

Prototype: Spironolactone

1. Amiloride

2. Triamterene

Potassium sparing diuretics Pharmacodynamics Spironolactone is an ALDOSTERONE antagonist Triamterene and Amiloride BLOCK the potassium secretion in the distal tubule Diuretic effect is achieved by the sodium loss to offset potassium retention

Pharmacodynamics

Spironolactone is an ALDOSTERONE antagonist

Triamterene and Amiloride BLOCK the potassium secretion in the distal tubule

Diuretic effect is achieved by the sodium loss to offset potassium retention

Potassium sparing diuretics

Potassium sparing diuretics Pharmacokinetics: Side effects HYPERkalemia! Avoid high potassium foods: Bananas Potatoes Spinach Broccoli Nuts Prunes Tomatoes Oranges Peaches

Pharmacokinetics: Side effects

HYPERkalemia!

Avoid high potassium foods:

Bananas

Potatoes

Spinach

Broccoli

Nuts

Prunes

Tomatoes

Oranges

Peaches

Osmotic Diuretics Prototype: Mannitol 1. Glycerin 2. Isosorbide 3. Urea

Prototype: Mannitol

1. Glycerin

2. Isosorbide

3. Urea

Osmotic Diuretics Pharmacodynamics Mannitol is a sugar not well absorbed in the nephron  osmotic pull of water  diuresis

Pharmacodynamics

Mannitol is a sugar not well absorbed in the nephron  osmotic pull of water  diuresis

Osmotic Diuretics Pharmacokinetics: side effects Sudden hypovolemia Important for the nurse to warm the solution to allow the crystals to DISSOLVE in the bottle!

Pharmacokinetics: side effects

Sudden hypovolemia

Important for the nurse to warm the solution to allow the crystals to DISSOLVE in the bottle!

Carbonic Anhydrase Inhibitors Prototype: Acetazolamide 1. Methazolamide

Prototype: Acetazolamide

1. Methazolamide

Carbonic Anhydrase Inhibitors Pharmacodynamics Carbonic Anhydrase forms sodium bicarbonate BLOCK of the enzyme results to slow movement of hydrogen and bicarbonate into the tubules plus sodium is lost in the urine

Pharmacodynamics

Carbonic Anhydrase forms sodium bicarbonate

BLOCK of the enzyme results to slow movement of hydrogen and bicarbonate into the tubules

plus sodium is lost in the urine

Carbonic Anhydrase Inhibitors Pharmacokinetics: side effects Metabolic ACIDOSIS happens when bicarbonate is lost Hypokalemia

Pharmacokinetics: side effects

Metabolic ACIDOSIS happens when bicarbonate is lost

Hypokalemia

The Nursing Process and the diuretics ASSESSMENT Assess the REASON why the drug is given: ______ ______ ______ ______

ASSESSMENT

Assess the REASON why the drug is given:

______

______

______

______

The Nursing Process and the diuretics ASSESSMENT The nurse must elicit history of allergy to the drugs Allergy to sulfonamides may contraindicate the use of thiazides Assess fluid and electrolyte balance Assess other conditions like gout, diabetes, pregnancy and lactation

ASSESSMENT

The nurse must elicit history of allergy to the drugs

Allergy to sulfonamides may contraindicate the use of thiazides

Assess fluid and electrolyte balance

Assess other conditions like gout, diabetes, pregnancy and lactation

The Nursing Process and the diuretics ASSESSMENT Physical assessment Vital signs Special electrolyte and laboratory examination Assess symptom of body weakness which may indicate hypokalemia

ASSESSMENT

Physical assessment

Vital signs

Special electrolyte and laboratory examination

Assess symptom of body weakness which may indicate hypokalemia

The Nursing Process and the diuretics Nursing Diagnosis Fluid volume deficit related to diuretic effect Alteration in urinary pattern Potential for injury (ototoxocity, hypotension) Knowledge deficit

Nursing Diagnosis

Fluid volume deficit related to diuretic effect

Alteration in urinary pattern

Potential for injury (ototoxocity, hypotension)

Knowledge deficit

The Nursing Process and the diuretics IMPLEMENTATION Administer IV drug slowly Safety precaution for dizziness/hypotension Provide potassium RICH foods for most diuretics, with the exception of spironolactone Provide skin care, oral care and urinary care

IMPLEMENTATION

Administer IV drug slowly

Safety precaution for dizziness/hypotension

Provide potassium RICH foods for most diuretics, with the exception of spironolactone

Provide skin care, oral care and urinary care

The Nursing Process and the diuretics IMPLEMENTATION Monitor DAILY WEIGHT- to evaluate the effectiveness of the therapy Monitor urine output, cardiac rhythm. Serum electrolytes ADMINISTER in the MORNING! Administer with FOOD!

IMPLEMENTATION

Monitor DAILY WEIGHT- to evaluate the effectiveness of the therapy

Monitor urine output, cardiac rhythm. Serum electrolytes

ADMINISTER in the MORNING!

Administer with FOOD!

The Nursing Process and the diuretics EVALUATION: for effectiveness of therapy Weight loss Increased urine output Resolution of edema Decreased congestion Normal BP

EVALUATION: for effectiveness of therapy

Weight loss

Increased urine output

Resolution of edema

Decreased congestion

Normal BP