Module 9 Diuretics Lecture Study Guide Fall 2023 PDF

/Module 9 Lecture Study Guide Fall 2023 Diuretics Kidneys primary function→ filtration Starts in the glomerulus then enter the nephrons→ nephrons excrete Na & chloride→ each nephron secretes a different % All diuretics block Na and chloride from being absorbed Osmotic—Osmotol (Mannitol) ● Location o...

/Module 9 Lecture Study Guide Fall 2023 Diuretics Kidneys primary function→ filtration Starts in the glomerulus then enter the nephrons→ nephrons excrete Na & chloride→ each nephron secretes a different % All diuretics block Na and chloride from being absorbed Osmotic—Osmotol (Mannitol) ● Location of nephron ○ Proximal convoluted tubule (PCT) ● MOA ○ Blocks PCT from reabsorbing NaCl; creates osmotic force within the lumen of nephron ● SE ○ HA, Nausea, Vomiting ● Indications ○ Increased ICP/cerebral edema ○ Intraocular pressures ● Contraindication ○ CHF; pulmonary edema ● Monitoring ○ Edema→ due to it NOT crossing the capillary membrane ○ Electrolytes ○ I&O balance ● Facts/Population Considerations ○ Does not cross BBB or capillary membrane ○ Very potent diuretic Loop—Furosemide (Lasix) Torsemide (Demadex) Bumetanide (Bumex) ● MOA ○ Blocks thick loop of henle from reabsorbing Nacl ● SE ○ Hypotension ● ● ● ● ○ Hyponatremia ○ Hypochloremia ○ Hypokalemia→ dysrhythmias→ interacts w/ Digoxin ○ Hypocalcemia→ muscle spasms/tetany ○ Ototoxicity–especially if you push too fast IVP ○ May cause hyperglycemia in some pts Indications ○ 1st line tx for HF FVO acute/chronic ○ 1st line for cardiorenal syndrome ○ ESLD—concurrent use of loop w/ AA diuretics to prevent hepatic encephalopathy Contraindications ○ Hypotension ○ BBW–for hyponatremia due to dehydration ○ caution w/ renal pts Monitoring ○ renal/electrolytes ■ NSAIDs may blunt effects due to prostaglandins being released→ dilation of glomerulus→ decreased blood flow Facts/Population Considerations ○ Furosemide is the least bioavailable but is the most common RX ○ Caution with someone w/ a sulfa allergy Thiazide—Hydrochlorothiazide (HCTZ) Metolazone (Zaroxolyn) Chlorthalidone (Thalitone) Chlorothiazide (Diuril) ● MOA ○ Blocks DCT from reabsorbing NaCl ● SE ○ Hypotension ○ dizziness/weakness ○ hyponatremia/hypomagnesemia, hypokalemia, hypercalcemia ● Indications ○ HTN & edema ○ Induces vasodilation→ 1st line tx for HTN ○ Given for HF w/ ACEI ● Contraindications ○ AKI hold if CrCl < 20 ○ ESRD ○ Hx of SJS ● Monitoring ○ renal/electrolytes ○ Uric acid levels if hx of gout ○ Increase risk of SJS & photosensitivity ○ Increases blood sugar→ caution w/ diabetics ● Facts/Population Considerations ○ Less effective than loops ○ Careful with NSAIDs due to prostaglandins ○ Crosses the placenta→ category B (do not take if pregnant) **Aldosterone→ secreted from the zona glomerulosa (adrenal cortex) AA/Potassium Sparing/MRA—Spironolactone (Aldactone) Eplerenone (Inspra) ● MOA ○ Same as thiazides, but spares K+ ● SE ○ Gynecomastia (swollen male breast tissue) ○ Hyperchloremic metabolic acidosis (loss of bicarb) ○ Hyperkalemia ● Indications ○ 3rd/4th line tx for HTN ○ Use in GDMT for HFrEF if CrCl > 30 and K+ is WNL ○ Hyperaldosteronism ○ Cirrhosis ○ Nephrotic syndrome ○ Hypokalemia ○ Off label use—acne mostly in women ● Contraindications ○ Acute renal failure ○ ESRD ○ Hyperkalemia ● Monitoring ○ renal/electrolytes ○ I&Os ● Facts/Population Considerations ○ Weak–rarely used solo ○ Women should be cautious if they want to avoid becoming pregnant and have some form of birth control ○ Watch diet high in K+ Carbonic Anhydrase Inhibitors—Acetazolamide (Diamox) ● MOA ○ Inactivates carbonic anhydrase→ PCT increases excretion of HCO3, taking Na+ H2O and K+ with it ○ Alkalines our urine and promotes diuresis ● SE ○ Hyperchloremic metabolic acidosis ○ Hypokalemia; hyponatremia ○ Hyperammonemia ○ Dehydration ● Indications ○ Refractory volume overload (pt not responsive to loop diuretics) ○ Most commonly when ppl have altitude sickness or correct metabolic alkalosis ○ Acute closed angle glaucoma ○ Pseudotumor cerebri ● Contraindications ○ Hyperchloremic metabolic acidosis ○ hypokalemia/natremia ○ Hyperammonemia ○ Dehydrated ● Monitoring ○ renal/electrolytes/acid base ○ I&Os Drug interactions for diuretics -digoxin -NSAIDs -ACEI (good interaction–synergy) First Line Anti-HTN SNS→ baroreceptors -Beta 1–cardiac output -Alpha 1–vasoconstriction -Vascular smooth muscle receptors & Kidneys -RAAS -alpha 1 ● Which medications are First line ○ Start with thiazide diuretics unless CKD, then ACEI or ARBs, then CCB ○ With any CKD, consider ACEI or ARBs regardless of ethnicity ● Which medications are Second line ○ Spironolactone, direct renin inhibitors, vasodilators (if HF or angina for afterload reduction), alpha blockers, beta blockers ● Specialty populations ○ CKD–ACE/ARB ○ diabetes–ACE/RB early ○ HF–ACE?ARB early ○ Pregnant–no ACE/start ARB or renin inhibitor HCTZ ● Look at above in diuretics section ACEi—”pril” Lisinopril, benazepril, enalapril, ramipril, captopril ● MOA ○ Blocks conversion of angiotensin I to II ● SE ○ hyperK+ ○ Angioedema ○ Cough ○ First dose hypotension ● Indications ○ 1st line tx before ARBs in HTN and post MI (helps remodeling) ○ Diabetic nephropathy ● Contraindications ○ HFrEF in AMI (start ARB instead) ○ pregnancy–BBW ○ Renal artery stenosis ○ Concurrent use of spironolactone or lithium ○ Hx of angioedema ● Monitoring ○ Renal function ○ Avoid use with NSAIDs ARB—”artan” Valsartan, Losartan ● MOA ○ Competitively inhibits angiotensin II on smooth muscle, heart, and adrenal glands→ dilation ● SE ○ Angioedema ○ Renal failure ● Indications ○ HTN, HF, diabetic nephropathy/retinopathy, MI, CVA prevention ○ Preferred over ACE with HF ● Contraindications ○ Pregnancy ○ Renal artery stenosis ● Monitoring ○ Renal function ○ Avoid with NSAIDs ● Facts/Population Considerations ○ May have less effect of first dose hypotension ○ No significant hyperK+ CCB—”pine” amlodipine, nicardipine, nifedipine [Dihydropyridines = HTN] ● MOA ○ Blocks Ca channels on peripheral smooth muscle (blood vessels)--> vasodilation ● SE ○ Reflex tachycardia ○ Edema ○ Dizziness, HA, flushing ○ Negative inotropy–will decrease contractility ● Indications ○ HTN, dysrhythmias. Angina, sometimes migraines ● Contraindications ○ Known HF–except amlodipine ○ Avoid immediate release in post MI or unstable angina ● Monitoring ○ BP/MAP ○ renal/electrolytes ● Facts/Population Considerations ○ Non-dihydropyridines don’t end in “pine” and are for arrhythmias Second Line Anti-HTN Renin Inhibitors—Aliskiren (Tekturna) ● MOA ○ Decrease plasma renin activity→ prevents conversion of angiotensinogen to angiotensin I and then angiotensin II→ vasodilation ● SE ● ● ● ● ○ Cough ○ Angioedema ○ Diarrhea ○ hyperK Indications ○ HTN ○ Combined with CCB or HCTZ Contraindications ○ Acute renal failure (CrCl < 30) ○ ESRD ○ Pregnancy ○ Renal artery stenosis Monitoring ○ Renal; liver Facts/Population Considerations ○ Give with low fat meal Alpha 1 Antagonist (blockers) —”zosin” doxazosin (Cardura) Prazosin, Terazosin ● MOA ○ Blocks vascular alpha 1 receptors on smooth muscle→ vasodilation ● SE ○ HA, dizziness ○ Nausea ○ Postural hypotension ● Indications ○ HTN ○ Off label use: BPH, PTSD nightmares, Raynaud’s, Dermal necrosis r/t IV infiltration ● Contraindications ○ Use with PDE5I like sildenafil ○ Use with TCAs (triptylines) ● Monitoring ○ Renal; liver, BP Alpha 2 Agonist (centrally acting) Clonidine, Methyldopa, Guanfacine ● MOA ○ Reduce sympathetic outflow from vasomotor centers in brainstem & increase parasympathetic outflow→ blocks NE availability→ vasodilation ● SE ○ Sedation, euphoria, crosses BBB ○ Nasal congestion, dry mouth ○ HA, dizziness, weakness ○ Rebound HTN ● Indications ○ HTN ○ Off label: pain, opioid withdrawal, smoking cessation, tourette’s, ADHD, delirium ● Contraindications ○ Substance use with other stimulants ○ pregnancy ● Monitoring ○ Potential for abuse ○ Methyldopa→ anemia & liver toxic ○ Clonidine→ vivid dreams/nightmares, xerostomia Beta Blockers ● 1st Generation BB (non cardiac selective) ○ Propranolol, sotalol, timolol, nadolol ● MOA ○ Blocks beta 1 to decrease HR & contraction and blocks beta 2 ● SE ○ Bradycardia ● ● ● ● ○ Hypotension ○ Hypoglycemia ○ Fatigue; dizziness Indications ○ HTN, pheochromocytoma, afib ○ Off label: anxiety, angina, elevated intraocular pressure/glaucoma Contraindications ○ Asthma; COPD ○ 2nd or 3rd degree heart block ○ Pregnancy→ propranolol Monitoring ○ BG; HR; BP; overdose Facts/Population Considerations ○ Reversal agent: glucagon 2nd Generation BB ● Atenolol, metoprolol, esmolol, bisoprolol ● MOA ○ Same as 1st gen–blocks beta 1 ○ Renal beta 1 = decreases renin ○ No effect on the lungs ● SE ○ Same as above ● Indications ○ HTN, HF, dysrhythmias, angina/MI ● Contraindications ○ Pregnancy ○ Heart blocks ● Monitoring ○ Same as above ● Facts/Population Considerations ○ Safer for asthmatics, diabetics, and PVD ○ Metoprolol has 2 types: tartrate (HTN) & succinate (HF) 3rd Generation BB ● Labetalol; carvedilol ● MOA ○ Blocks alpha 1→ vasodilation ○ Blocks beta 1 & 2 ● SE ○ Same as above ● Indications ○ HTN, MI, HF ● Contraindications ○ Abruptly stopping→ increase risk of MI ○ Caution with digoxin & CCBs ○ CHB ● Monitoring ○ Same as above **Meds to avoid in pregnancy -ACE/ARB/RI -propranolol -atenolol, metoprolol, bisoprolol First line tx for pregnancy -labetalol & methyldopa 2nd line tx -nifedipine -HCTZ Vasodilators Hydralazine ● MOA ○ Same as NTG + acts on Ca channels (dilates arteries ONLY) ● SE ○ HA ○ reflex HTN/tachy ○ Nausea ● Indications ○ HTN ○ HFrEF especially in people of color ● Contraindications ○ Renal failure ○ pregnancy?? ● Monitoring ○ HR/BP ● Facts/Population Considerations ○ Risk of SLE Sodium Nitroprusside ● MOA ○ Same as hydralazine ● SE ○ Cyanide toxicity→ delirium, psychotic behavior ○ Brady; hypo ○ Heart blocks; HF ● Indications ○ HTN urgency/emergency ○ GMDT for acute diastolic HF exacerbation ● Contraindications ○ Renal failure ● Monitoring ○ Needs to be in ICU Anginal Medications/vasodilators for acute & chronic angina NTG ● MOA ○ Act directly on smooth muscle of arterioles via nitric oxide→ relaxation→ decreased afterload→ decreased O2 demand→ dilation of venous system ● SE ○ Hypotension ○ HA, flushing ○ Reflex tachy→ palpitations ● Indications ○ Angina ● Contraindications ○ Glaucoma, migraines, ED (on meds), CVA, CrCl < 50 ● Monitoring ○ HR/BP. Nitro free time (to prevent tolerance), edema, renal ● Facts/Population Considerations ○ For MI, avoid morphine & oxygen but keep ASA and NTG Isosorbide Mononitrate ● MOA ○ Directly relax smooth muscles to cause vasodilation including coronary arteries ● SE ● ● ● ● ○ HA, dizziness ○ Postural Hypotension, reflex tachy ○ Worsen angina ○ Dry mouth, hot flashes Indications ○ Chronic angina Contraindications ○ ACUTE angina Monitoring ○ BP ○ Tolerance Facts/Population Considerations ○ Pt should take in AM ○ For extended release→ stop slowly Hydralazine + Isosorbide Dinitrate ● MOA ○ Hydralazine vasodilates smooth muscle and isosorbide restores nitric oxide and dilates arteries & veins ● SE ○ Hypotension, tachy ○ HA, dizziness, flushing ○ SLE flare ups ● Indications ○ Chronic angina ● Contraindications ○ Acute angina ○ Sildenafil with ED ● Monitoring ○ BP ○ Tolerance ● Facts/Population Considerations ○ Stop med if having SLE flare up CCB for Angina ● Use if unable to tolerate BB ● Nifedipine = drug of choice bc it’s long acting ○ Other options: amlodipine, diltiazem, verapamil ● Use amlodipine if pt has angina AND heart failure Ranolazine (Ranexa) ● MOA ○ Disrupts Na & K channels→ decrease HR and O2 demand ● Can be used with nitrates, BB, or CCB ● SE ○ QT prolong ○ Hypo ○ Brady ○ Edema ● Contraindications ○ Not for acute angina ○ Adjust dose if CrCl < 50 Heart Failure ARNI—Sacubitril/Valsartan (Entresto) ● MOA ○ Neprilysin inhibitor (sacubitril) prevents breakdown of natriuretic peptides + MOA of ARB = double blockage of RAAS ● SE ○ Hypotension ○ Angioedema ○ hyperK ○ Increased bradykinin ● Indications ○ HFrEF ● Contraindications ○ Use w/ ACE—need 36 hr washout ○ Pregnancy ○ ESRD ○ Liver failure ● Monitoring ○ BP, renal, liver, K+ ● Facts/Population Considerations ○ Don’t need 36 hr washout if already taking valsartan ○ Hold or reduce dose if CrCl < 30 BB in Heart Failure ● Which 3 ○ Metoprolol succinate, carvedilol, bisoprolol ● GDMT ○ Start low and go slow ○ Better to start when pts are “dry” aka not in acute exacerbation AA/MRA in HF—Spironolactone ● Only if CrCl < 30 and K+ WNL ● Improves blockage of RAAS when used w/ ACE/ARB/ARNI ● If pt has acute diastolic HF and loop diuretic resistance→ add spironolactone ● Watch for endocrine issues: gynecomastia (enlarged breasts) and galactorrhea (milk production unrelated to pregnancy) SGLT2 Inhibitors in HF—-”glifozin” dapaglifozin (farxiga) empagliflozin (jardiance) ● MOA ○ Sodium-glucose cotransporter in proximal tubule that is responsible for 90% of urinary glucose reabsorption→ also cause diuretic effects, weight loss, and lowering BP ● SE ○ Hypoglycemia ○ Electrolyte imbalance ● Indications ○ HFmrEF; HFrEF ● Contraindications ○ ESRD (if CrCl < 20) ● Monitoring ○ Risk for UTI/pyelonephritis ○ BP; BG, electrolytes HF and Diuretics ● Which classes? ○ Loop or thiazide ○ Why is it recommended? ■ Maintain euvolemia, relieve congestion, improve symptoms and prevent worsening HF ● Use in acute and chronic renal disease Heart Failure and Oral Vasodilators ○ Which medications ■ Hydralazine & isosorbide dinitrate ○ Why is it recommended? ■ Afterload reduction and decrease cardiac related deaths ■ Excellent sub for ACE if pt can’t handle the dry cough