Diuretics are drugs that promote the excretion of sodium and water from the body by acting on the kidney. They work by interfering with sodium transport mechanisms in different segments of the nephron. The main types are loop diuretics which act on the thick ascending limb of the loop of Henle, thiazide diuretics which act on the early distal tubule, and potassium-sparing diuretics which act on the late distal tubule and collecting duct. Diuretics are important drugs used to treat hypertension, heart failure, and edema.
Diuretics | Definition | Mechanism of Action | Classes of DrugsChetan Prakash
This presentation provides knowledge about Diuretics,Role of sodium, types of urine output, General mechanism of action, Normal Physiolofy of urine formation, GFR Formation, Classes of Diuretics, diuretics abuse and recent discovery. An assignment for the subject, Advanced Pharmacology-I, 1st year M.Pharm, 1st semester.
Diuretics
Pharmacology
Katzung
Abnormalities in fluid volume and electrolyte composition are common and important clinical disorders. Drugs that block specific transport functions of the renal tubules are valuable clinical tools in the treatment of these disorders. Although various agents that increase urine volume (diuretics) have been described since antiquity, it was not until 1937 that carbonic anhydrase inhibitors were first described and not until 1957 that a much more useful and powerful diuretic agent (chlorothiazide) became available. Technically, a “diuretic” is an agent that increases urine volume, whereas a “natriuretic” causes an increase in renal sodium excretion and an “aquaretic” increases excretion of solute-free water. Because natriuretics almost always also increase water excretion, they are usually called diuretics. Osmotic diuretics and antidiuretic hormone antagonists (see Agents That Alter Water Excretion) are aquaretics that are not directly natriuretic.
Diuretics | Definition | Mechanism of Action | Classes of DrugsChetan Prakash
This presentation provides knowledge about Diuretics,Role of sodium, types of urine output, General mechanism of action, Normal Physiolofy of urine formation, GFR Formation, Classes of Diuretics, diuretics abuse and recent discovery. An assignment for the subject, Advanced Pharmacology-I, 1st year M.Pharm, 1st semester.
Diuretics
Pharmacology
Katzung
Abnormalities in fluid volume and electrolyte composition are common and important clinical disorders. Drugs that block specific transport functions of the renal tubules are valuable clinical tools in the treatment of these disorders. Although various agents that increase urine volume (diuretics) have been described since antiquity, it was not until 1937 that carbonic anhydrase inhibitors were first described and not until 1957 that a much more useful and powerful diuretic agent (chlorothiazide) became available. Technically, a “diuretic” is an agent that increases urine volume, whereas a “natriuretic” causes an increase in renal sodium excretion and an “aquaretic” increases excretion of solute-free water. Because natriuretics almost always also increase water excretion, they are usually called diuretics. Osmotic diuretics and antidiuretic hormone antagonists (see Agents That Alter Water Excretion) are aquaretics that are not directly natriuretic.
Cardiovascular pharmacology
Cardiovascular (=Circulatory) system – heart and blood vessels
Arteries – transport blood to tissues
Capillaries – sites of exchange, fluid O2, CO2, nutrients etc.
Venules – collect blood from capillaries
Veins – transport blood back to heart
Blood moves within vessels – higher pressure to lower pressure
Resistance to flow depends on vessel diameter, length and viscosity of blood
Desmopressin
Lypressin
Terlipressin
Felypressin
Argipressin
ornipressin
Desmopressin: It is a selective V2-receptor agonist and is more potent than vasopressin as an antidiuretic. It has negligible vasoconstrictor action. It is administered by oral, nasal and parenteral routes. Lypressin: It acts on both V1- and V2-receptors. It is less potent but longer acting than vasopressin. It is administered parenterally. Terlipressin: It is a prodrug of vasopressin with selective V1 action. It is administered intravenously. Felypressin: It is a synthetic analogue of vasopressin. It is mainly used for its vasoconstrictor (V1 ) action along with local anaesthetics to prolong the duration of action. Felypressin should be avoided in pregnancy because of its oxytocic (uterine stimulant) activity.
This Presentation tries to make understand the System which plays a role in increasing Blood Pressure-Renin Angiotensin System & How the drugs and inhibiting Enzymes prevent this BP rise...
Diuretics and antidiuretics detail STUDYNittalVekaria
diuretics and antidiuretics detail study
-diuretic are the drug which increase the urine formation and excretion.
- antidiuretic work by decrease the urine formation.
classification, mechanism of action, use ,pharmacokinetic, pharmacodynamic,adverse effect
-newer drug
-banned diuretic and antidiuretic drug
Cardiovascular pharmacology
Cardiovascular (=Circulatory) system – heart and blood vessels
Arteries – transport blood to tissues
Capillaries – sites of exchange, fluid O2, CO2, nutrients etc.
Venules – collect blood from capillaries
Veins – transport blood back to heart
Blood moves within vessels – higher pressure to lower pressure
Resistance to flow depends on vessel diameter, length and viscosity of blood
Desmopressin
Lypressin
Terlipressin
Felypressin
Argipressin
ornipressin
Desmopressin: It is a selective V2-receptor agonist and is more potent than vasopressin as an antidiuretic. It has negligible vasoconstrictor action. It is administered by oral, nasal and parenteral routes. Lypressin: It acts on both V1- and V2-receptors. It is less potent but longer acting than vasopressin. It is administered parenterally. Terlipressin: It is a prodrug of vasopressin with selective V1 action. It is administered intravenously. Felypressin: It is a synthetic analogue of vasopressin. It is mainly used for its vasoconstrictor (V1 ) action along with local anaesthetics to prolong the duration of action. Felypressin should be avoided in pregnancy because of its oxytocic (uterine stimulant) activity.
This Presentation tries to make understand the System which plays a role in increasing Blood Pressure-Renin Angiotensin System & How the drugs and inhibiting Enzymes prevent this BP rise...
Diuretics and antidiuretics detail STUDYNittalVekaria
diuretics and antidiuretics detail study
-diuretic are the drug which increase the urine formation and excretion.
- antidiuretic work by decrease the urine formation.
classification, mechanism of action, use ,pharmacokinetic, pharmacodynamic,adverse effect
-newer drug
-banned diuretic and antidiuretic drug
the detail study of diuretics which include their drugs, use,classification of diuretics, side effect, mechanism of action, metabolism, synthesis etc. this all things are cover in this presentation.
Pharmacology of drugs acting on Renal System.pdfAFFIFA HUSSAIN
Diuretics also known as water pills increases the excretion of water and electrolytes (Na+) in
urine.
Natriuresis – large amount of sodium excreted in urine due to the action of kidneys.
Promoted by – ventricular and atrial natriuretic as well as calcitonin.
Inhibited by chemicals such as aldosterone. The drugs which increases sodium excretion are
known as natriuretic.
Diuresis – increased or excessive production of urine. The drugs which enhances the excretion
of water without loss of electrolyte is called as aquaretic.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journey
Diuretics
1. DIURETICS
Presented to:
Dr. S.N. Manjula. M.Pharm, Ph.D.
Professor & Head
Department of Pharmacology
JSS College of Pharmacy, Mysuru
Presented by:
Naveen Reddy .P 1st M.Pharm
Department of Pharmacology
JSS College of Pharmacy,
Mysuru
Antihypertensive
2. 2
Natriuretic - Increasing renal Sodium excretion
Kaliuretic - Increasing renal Potassium excretion
Calciuretic – Enhanced calcium excretion
Saluretic – Enhanced sodium chloride excretion
Diuretics (WATER PILLS)- Increasing loss of Na+ and water in urine.
TERMINOLOGY
3. 3
Kidney
- Weight- 0.5% of total Body, Rk 81-160g Lk 83-176g.
- Cardiac Output- 25% of total (50 times)
Functions ( BASE )
- B alance of Electrolytes, Volume, pH, BP
- A ctivation of Vitamin D
- S ynthesis of Erythropoietin
- E xcretion of Toxins, metabolites
Transport types
- Passive- Simple, channel mediated and facilitated diffusion, solvent drag.
- Active- Primary and Secondary (Symports and Counter transport)
RENAL PHYSIOLOGY
5. 5
STRUCTURE AND FUNCTION
Each nephron consists of a :
1. Glomerulus,
2. Proximal Tubule,
3. Loop of Henle,
4. Distal Convoluted Tubule and
5. Collecting Duct
6. 6
Proximal Convoluted Tubule: Site-1
• Most of the filtered Na+ is actively
reabsorbed; chloride is reabsorbed
passively along with sodium.
• Carbonic anhydrase plays an
important role in Na+ H+ exchange
and helps in the reabsorption of
HCO3-. Potassium, glucose, amino
acids etc. are also reabsorbed in the
PCT.
• Proportionately water also gets
reabsorbed, so tubular fluid in the
PCT remains isotonic.
7. 7
Loop of Henle • The descending limb
is miserable to Na+ and urea and
highly permeable to water. • Hence
fluid in the loop become hypertonic.
Thick Ascending Limb of Loop of
Henle: Site-2
• The thick ascending limb is
permeable to water but highly
permeable to Na+ and Cl-.
• Active reabsorption of sodium and
chloride occurs by Na+-K+, 2Cl-
Co- transporter. This is selectively
blocked by loop diuretics.
• Ca2+ and Mg2+ are also
reabsorbed at this site.
8. 8
Early Distal Table: Site-3
• It is impermeable to water but
sodium and chloride are
reabsorbed with the helps of
Na+, Cl- symporter.
• This is blocked by thiazide.
9. 9
Early Distal Tubule and Collecting
Duct: Site-4
• Sodium is actively reabsorbed;
chloride and water diffuse passively.
• Exchange of Na+- K+, H+ ions occur.
The Na+- K+ exchange under the
influence of aldosterone (aldosterone
promote Na+ absorption and K+
depletion).
• Absorption of fluid in the collecting
duct (CD) is under the influence of
ADH. In the absence of ADH, the CD
becomes impermeable to water and
large amount of dilute urine is
excreted.
• Normally H+ ions present in urine
convert NH3 to NH4 which is excreted.
10. 10
!Diuretics are the drugs which increase the rate of urine formation causing a net loss of Na+ and
water, by interfering with transport mechanism responsible for the reabsorption of solutes from
various segments of the nephron
or
!Diuretics are the drugs that promote the excretion of Na+ and water from the body by an action on
the kidney.
!Very important cardiovascular drugs ▪ Management of chronic heart failure ▪ Anti-hypertensives
(third-line)
!Increase Na+ excretion - NATRIURESIS
• Na+ movement is followed osmotically by water (diuresis)
• Decrease extracellular / plasma volume
– Reduce oedema
– Reduce blood pressure
DIURETICS
11. 11
Antihypertensive Drugs
Classification of diuretics
1. Drugs acting at proximal convoluted tubule (PCT) Site-1
- Carbonic anhydrase inhibitor: Acetazolamide
2. Drugs acting at thick ascending limb of loop of Henle Site-2
- Loop diuretics: furosemide, bumetadine, torsemide, ethacrynic acid.
3. Drugs acting at early distal tubule Site-3
- Thiazides: chlorothiazide, hydrochlorothiazide, polythiazide. Benzthiazide.
- Thiazide related diuretics: chlorthalidone, indapamide, metolazone.
4. Drugs acting at late distal tubule and collecting duct Site-4
- Aldosterone antagonist: spironolactone and eplerenone.
- Direct inhibitor of Na+ channels: Amiloride and triamterene.
5. Drugs acting on entire nephron (main site of action in loop of Henle)
- Osmotic diuretics: Manito, glycerol, isosorbide.
CLASSIFICATION
12. 12
1) Carbonic Anhydrase Inhibitors
Mechanism of action:
• Both CO2 and H2O diffuse into the tubular cell where H2CO3 is
formed under the influence of carbonic anhydrase.
• Carbonic acid dissociates into H+ and HCO3-.
• The H+ ions exchange with luminal Na+ .
• In the lumen the H+ ions combine with HCO3- and form H2CO3.
• The H2CO3 dissociates into CO2 and H2O with the help of
carbonic anhydrase, which is present near the brush border.
• The main site of action of acetazolamide is proximal tubule. it
also acts in the collecting duct.
• Acetazolamide by inhibiting carbonic anhydrase enzyme, prevents
the formation of H+ ions. Na+ H+ exchange is prevented.
• Na+ is excreted along with HCO3- in urine.
• In the DCT, increase Na+, K+ exchange leads to loss of K+. The
net effect is loss of Na+, K+ and HCO3- in urine resulting in
alkaline urien.
ATZ
(PCT) Site-1
13. 13
Uses of CAI • Acetazolamide is not used as diuretic because of its low efficacy.
It is used in the following condition:
1. Glaucoma: CAI decrease the intraocular pressure by reducing the formation of aqueous humor.
2. Acute mountain sickness: The beneficial effect to decrease the PH and formation of
cerebrospinal fluid.
3. To alkalinize urine in acidic drug poisoning.
Adverse effect of CAI • Hypersensitivity reaction • Skin rashes • Fever • Drowsiness • Hypokalemia
• Metabolic acidosis • Headache • Renal stone.
Contraindication of CAI
• LIVER DISEASE: Hepatic coma may be precipitated in patient with cirrhosis due to decreased
excretion of NH3 in alkaline urine.
• COPD: Worsening of metabolic acidosis is seen in patient with chronic obstructive pulmonary
disease
(PCT) Site-1
14. 14
2) Loop Diuretics (high ceiling diuretics)
MOA: Sites of action is the ascending limb of loop of
Henle. Loop diuretics binds to luminal side of Na+, K+
2Cl- cotransporter and block its function. There is an
increased excretion of Na+ and Cl- in urine.
•The tubular fluid reaching the DCT contains large
amount of Na+. Hence more Na+ exchanges with K+
loss.
•Furosemide has weak carbonic anhydrase inhibiting
activity hence increase the excretion of HCO3- and
PO34-.
•They also increase the excretion of Ca2+ and Mg2+.
•Loop diuretics are called high-celling diuretics
because they are highly efficacious – have maximal
Na+ excreting capacity when compared to thiazides
and potassium sparing diuretics.
loop of Henle Site-2
15. 15
Therapeutic uses of furosemide
• During the initial stage of renal, hepatic and cardio oedema, loop diuretics are preferred.
• Intravenous furosemide, along with isotonic saline is used in hypercalcemia as it promotes the excretion of Ca2+ in
urine.
• Acute pulmonary oedema- loop diuretics Produce quick relief from pulmonary oedema.
• Loop diuretics may be used in cerebral oedema but IV Manitol is the preferred drug.
• Hypertension: loop diuretics can be used in hypertensions associated with CCF/ renal failure and in hypertensive
emergencies.
• Furosemide is not preferred in uncomplicated primary hypertension because of short duration of action.
• Loop diuretics can be used in the mild hyperkalemia.
• Loops block Na+/ K+/ 2Cl- symporter
• Decrease NaCl entry into macula densa tubular cells
- promotes renin release, leading to increased AngII activity
• → Kidney becomes refractory to LDs for some hrs after use
- due to activation of RAAs
loop of Henle Site-2
16. 16
Adverse effect
1. Electrolyte disturbances: are the common adverse effects seen with loop diuretics. They are:
A. Hypokalemia: it is the most important adverse effect. It can caused fatigue, muscular weakness and cardiac
arrhythmia, especially in patients taking digitalis. It can be treated by K+ supplementation.
B. Hyponatremia: overuse of loop diuretics can cause depletion of sodium from the body.
C. Hypokalemic metabolic alkalosis: as less K+ is available for exchange with Na+ in the DCT, more Na+/ H+
exchange takes place leading to H+ loss, thus causing hypokalemic alkalosis.
D. Hypocalcaemia and hypomagnesaemia: These are due to the increased urinary excretion of Ca2+ and
Mg2+ respectively.
2. The metabolism disturbances include:
Hyperuricaemia: these drug decrease the renal excretion of uric acid and may precipitate attacks of gout.
Hyperlipidemia: they increase plasma triglycerides and LDL cholesterol levels.
3. Hypersensitivity: skin rashes, eosinophilia, photosensitivity etc. may occur.
Drug interaction
• Furosemide × digoxin (digoxin toxicity)
• Furosemide × aminoglycoside (Ototoxicity)
• Furosemide × NSAIDs (diminish effect of LD)
• Furosemide × lithium (lithium toxicity)
• Furosemide × amiloride (synergistic effect)
loop of Henle Site-2
17. 17
3) Thiazide- like diuretics
• Chlorthalidone is a frequently used thiazide like diuretic in hypertension as it has a long duration of
action. Indapamide and metolazone are more potent, longer acting and produce fewer adverse
effects than thiazides.
MOA: Thiazides inhibits Na+ Cl- symport in early distal tubule and increase Na+ and Cl- excretion.
• There is increased delivery of Na+ to the late distal tubule, hence there is increased exchange of
Na+ K+ which results in K+ loss.
• Some of thiazide also have weak carbonic anhydrase inhibitory action and increase HCO3- loss.
• Therefore there is a net loss of Na+, K+, Cl-, Hco3- in urine. Unlike loop diuretics, thiazides
decrease Ca2+ excretion.
• Also used in mild to moderate heart failure
• Thiazides are renally secreted to act on DCT, thiazides are
deemed ineffective in moderate renal impairment (except
metolazone)
DT Site-3
18. 18
Pharmacokinetics: Thiazide are administered orally. They have long duration and are excreted in
urine.
Uses: 1. Hypertension: thiazides are used in the treatment of essential hypertension.
2. Heart failure: thiazides are used for mild to moderate cases of heart failure.
3. Hypercalcemia: thiazides are used in calcium nephrolithiasis (Kidney stone) as they reduce the
urinary excretion of calcium.
Adverse effects 1. Thiazides cause electrolyte disturbance which include hypokalemia,
Hyponatremia, metabolic alkalosis, hypomagnesaemia.
2. The metabolic disturbances are similar to that of loop diuretics – hyperglycemia, hyperlipidemia
and hyperuricaemia.
3. They may cause impotence, hence thiazides are not the preferred antihypertensive in young
males.
4. Others: skin rashes, photosensitivity, gastrointestinal disturbances like nausea, vomiting, diarrhea
etc. can occur.
DT Site-3
19. 19
Hypokalaemia
Secondary to loop diuretics / thiazides
Due to K+ Loss – kaliuresis leading to hypokalaemia
1. Activation of RAAs → Na+ retention and K+ loss (actions of aldosterone & some via AngII)
via
i. Decrease Na+ in ECF (increased urinary Na+ loss)
ii.Volume depletion, “diuretic hypovolaemia”
iii. Loop diuretics block NaCl entry into macula densa cells
Loops block Na+/ K+/ 2Cl- symporter
2. Increase Na+ delivery to DCT
→ promotes K+ loss (secretion)
Increased renin release →
increase angiotensin II
production & aldosterone
release
Low body fluid
osmolality Low blood
volume Low blood
pressure
Inc Na+ reabsorption and
hence Inc H2O retention
DT Site-3
20. 20
Metabolic alkalosis
Secondary to loop diuretics / thiazides
• Increased Na+ delivery to late DCT & CD leads to enhanced Na+ reabsorption which is associated with H+
secretion/ loss
• Also activation of RAAs (with decreased ECF volume) leads to aldosterone activity (Inc H+ secretion)
→ decreased urinary pH
→ increased blood pH (alkalosis)
DT Site-3
21. 21
4) Potassium Sparing Diuretics
Aldosterone Antagonist • Spironolactone:
• it is an aldosterone antagonist. It is a synthetic steroid and structurally related to aldosterone.
• Aldosterone enters the cell and binds to specific mineral corticoid receptor (MR) in the cytoplasm
of late distal tubule and collecting duct cells.
• The hormone receptor complex enters the cell nucleus, where it induces synthesis of aldosterone
induced proteins (AIP).
• The net effect of AIP is to retain sodium and excrete potassium.
• Spironolactone competitively blocks the
mineral corticoid receptors and prevents the
formation of AIPs.
• Therefore, spironolactone promotes Na+
excretion and K+ retention.
Amiloride and Triamterene: (Directly Acting)
• Both are directly acting K+ sparing diuretics.
• They directly block the Na+ channels in the
luminal membrane of the cells of the late
DCT and CD.
CT Site-4
22. 22
Pharmacokinetics • Spironolactone is administered orally, gets partly absorbed and is highly
bound to plasma proteins; extensively metabolized in liver and forms active metabolite, canrenone,
which has long plasma half- life.
Uses • In edematous condition associated with secondary hyperaldosteronism. (congestive
cardiac failure, hepatic cirrhosis and nephrotic syndrome).
• Spironolactone is often used with thiazides / loop diuretics to compensate K+ loss.
• Resistant hypertension due to primary hyperaldosteronism. (conn’s syndrome)
Drug interaction
• ACE inhibitors × spironolactone
• Eplerenone an aldosterone antagonist is more selective for mineralocorticoid receptor. Hence it
is less likely to cause Gynacomastia.
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5) Osmotic diuretics
These include Mannitol, glycerol and isosorbide.
Manitol: it is administered intravenously. It is neither metabolized in the body nor reabsorbed from
the renal tubules.
It is pharmacologically inert and is freely filtered at the glomerulus.
20% of mannitol , on i.v administration
Increases in osmolality of plasma
Shift of fluid (osmotic effect) from intracellular
compartment(ICC) to extracellular fluid(ECF)
ECF ICC
Expansion of ECF volume
Increases glomerular filtration rate, mannitol is freely filtered
at the glomerulus
Increases osmolality of tubular fluid
Inhibits reabsorption of water and NaCl
The net effect is the increased urinary excretion of Na+, K+,
Ca+, Mg+, Cl-, HCO3 and PO43
Mechanism of action:
• osmotic diuretics draw water from tissues by
osmotic action.
• This results in increased excretion of water and
electrolytes.
• Their site of action is in the loop of Henle and
proximal tubule.
Renal blood flow
Blood flow to renal medulla
Tonicity in renal medulla
OSMOTIC DIURETICS
24. 24
Uses of osmotic diuretics 1. Mannitol is used to prevent acute renal shutdown in shock,
cardiovascular surgery, haemolytic transfusion etc.
2. Mannitol is used to reduce the elevated intracranial tension (ICT) following head injury or tumour. It
draws fluid from the brain into the circulation by osmotic effect, thus lowering ICT.
3. Mannitol 20% (IV), glycerol 50% (oral) and isosorbide (oral) are used to reduce the elevated IOP in
acute congestive glaucoma. They draw fluid from the eye by osmotic effect, in to blood – IOP is
decreased.
Adverse effects • Too rapid and too much quantity of iv Mannitol can cause marked expansion of
ECF volume which can lead to pulmonary oedema.
• Headache, nausea and vomiting may occur.
• Glycerol can cause hyperglycaemia.
Contraindication • Mannitol is contraindicated in CCF and pulmonary oedema because it expands
ECF volume by increasing the osmolality of extracellular compartment and increase the load on heart,
thus aggravating the above condition. Other contraindication are chronic oedema, anuric renal
disease and active intracranial bleeding.
OSMOTIC DIURETICS
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Diuretics Site of action MOA Efficacy
Acetazolamide PCT
Carbonic anhydrase
inhibitor
Low
Loop Diuretics
Thick ascending
limb of loop of
Henle
Inhibit Na+-K+-2Cl-
Cotransport
High
Thiazides Early distal tubule Inhibit Na+-Cl- Symport Medium
K+ sparing
diuretics
DT and CD
Aldosterone antagonists
(Spironolactone)
Directly acting (amiloride
and triamterene)
Low
Mannitol
Loop of Henle and
PCT
Osmotic effect High
Diuretics with their site and mechanism of action
DIURETICS
26. 26
Diuretics in practice
• Best taken in the morning
• Patients will experience an increase in urine flow
• May cause postural hypotension, esp. in elderly patients
• Thiazides (and loop diuretics less so) may uncover/worsen diabetes
• Thiazides and loop diuretics may worsen gout
• NSAIDs may reduce the effects of loop diuretics (reduced effects of renal PGs on renal blood flow)
• Patients should be advised to avoid excess salt in the diet
• Electrolytes should be monitored
DIURETICS
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1. Mechanism of action and ADR of Loop Diuretics ?
2. Classify diuretics with specific examples.
3. Explain the role of diuretic as antihypertensive therapy.
4. Define and Classify diuretics. Explain the Pharmacology of Furosemide.
QUESTIONS
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•Pharmacology for medical graduates Third edition by Tara V Shanbhag.
•Goodman & Gilman’s The Pharmacological Basis of THERAPEUTICS
•Essentials of Medical Pharmacology [7th Edition] by KD Tripathi
•Rang and Dale 8th Edition By H.P.Rang, J.M. Ritter
REFERENCES
Thank You