Diuretics
Classification and Details
Class | Drugs | Uses |
Carbonic Anhydrase Inhibitors | • Acetazolamide (DOC) • Dorsolomide (Topical) • Dichlorphenamide. | • Acute mountain sickness • Familial hypokalemic periodic paralysis. • C/I in liver cirrhosis ↳ Cause Hepatic encephalopathy • Not used as a diuretic Mnemonic: Ace chyth mountain climb cheyth |
Loop Diuretics | • Furosemide ↳ (DOC for pulmonary edema) • Torsemide (longest acting) • Bumetanide (most potent) • Ethacrynic acid (most ototoxic) | • Acute heart failure • Severe symptomatic hyponatremia • Pulmonary edema • Renal insufficiency (GFR <40) ↳ Loop diuretics is preferred ↳ if no response - add metalazone |
Thiazide | • Chlorthiazide • Hydrochlorothiazide | • Same as thiazide like diuretics |
Thiazide like diuretics | • Chlorthalidone ↳ Longest acting ↳ Preferred in HTN • Indapamide ↳ Hepatic excretion • Metolazone ↳ Effective if GFR <40 | DOC for • HTN with edema • HTN with osteoporosis • HTN with renal insufficiency → Metalozone (DOC) • Nephrogenic DI / Peripheral DI |
Potassium-Sparing Diuretics | • Finerenone Mnemonic: PASTE • Potassium sparing • Amiloride → ENa # • Spironolactone → Aldosterone # • Triamterene → ENa # • Eplerenone → Aldosterone # | Spironolactone/Eplerenone: • DOC for resistant HTN • DOC for Cirrhotic edema (+Furosemide) • DOC for Conn's Syndrome • Heart failure. Amiloride: DOC for • Lithium-induced DI • Liddle syndrome • Mnemonic: amiLo → LL |
Osmotic Diuretics | • Mannitol | • Acute congestive glaucoma • Braking of diuretics • Cerebral edema • Dialysis dysequilibrium • Impending renal failure Contraindications • Cerebral hemorrhage • Pulmonary edema |
Condition | DOC |
• HTN in pregnancy | Oral Labetalol > Methyldopa |
• HTN Emergency in pregnancy | IV Labetalol |
• HTN Emergency | Nicardipine > Nitroprusside |
• Hypertensive urgency • Cheese Reaction | Clonidine |
• Resistant Hypertension ↳ >140/90 mmHg ↳ Instead of ≥ 3 drugs including thiazides | Spironolactone |
• HTN with Diabetes | Telmisartan |
• HTN with Gout | Losartan |
HTN with • edema • osteoporosis • Renal stones/colic | Thiazide like diuretics |
HTN with • Nephrotic syndrome • Scleroderma • CKD | ACE I/ARBS |
• HTN with renal insufficiency (eGFR <40) | ↳ Loop diuretics is preferred ↳ if no response - add metalazone |
• HTN induced by cyclosporin • Raynauds D/s | CCBs |
• HTN with BPH | Prazosin |
HTN with • Migraine • Hyperthyroidism • Stable Angina • Anxiety disorder • Essential tremor | β Blocker |
Essential Tremor
- High-frequency tremor with sustained posture
- Tremor increases with activity, anxiety
- Initially tremor → then smoothens
- Decreases with alcohol
- Familial
- DOC: Propranolol
Intentional tremor
- Cerebellar tremor
- Start fine → tremor by the end
Mnemonic: Drugs causing Gynecomastia
- DISCO
- Di → Digoxin
- S → Spironolactone
- C, K → Cimetidine, Ketoconazole
- O → Oestrogen
- Mnemonic:
- LOOP diuretics
- FurOOsemide
- HypOOnatremia
- HypOOkalemia
- HypOOcalcemia
- GOOUT
- OOtotoxic
- Avoid with aminoglycosides
- Mnemonic:
- Limb → Loop
- CT → Convoluted tubule → Carbonic any, Thiazides
- Note:
- Cerebral edema d/t trauma → Mannitol
- Cerebral edema d/t tumors → Steroids
- Acute mountain sickness → Acetazolamide
Loop vs Thiazide
- Common
- ↓K, ↓Mg, ↓Na, ↓H
- ↑Sugar
- ↑Lipid
- ↑Uric acid
- Difference
- Loop → Loses Calcium → Hypocalcemia
- Thiazide → Hypercalcemia
Loop | Thiazide |
High ceiling | Weak |
Short | Long |
Used in edema | Used in HTN |
Inherited Tubular Disorders (ITDs)
Clinical Presentation
↓ Reabsorption of | Leads to |
Water | Polyuria → Polydipsia |
Electrolytes | Electrolyte imbalances |
Nutrients | Failure to thrive |
Syndromes in Renal transporters
Class | MOA & Site | Enzyme | Effects |
Carbonic Anhydrase Inhibitors / | PCT | Block carbonic anhydrase (Fanconi) ↳ Fanil acid ozhich ↳ Hypokalemic Metabolic acidosis | Acidazolomide ↳ Sulfa drug ↳ Hypokalemia ↳ Acidosis (HCO₃⁻ loss) |
Loop Diuretics | TAL | Block Na+-K+-2Cl- pump/ Chloride channel (Barttin) (Bartter syndrome) | Loop diuretics → all low • Hyponatremia • Hypokalemia • Gout • Hypochloremia • Hypocalcemia • Indirect vasodilators ↳ (↑ prostaglandins). Hypokalemic hypochloremic metabolic alkalosis + ↑Ca²⁺ excretion (Nephrocalcinosis) |
Thiazides | DCT | Block Na-Cl cotransporter (Gitelman syndrome) Gitel man → Gita maggy (magnesium) undakk | • Hyponatremia • Hypokalemia • Gout • Postural Hypotension • Hyperglycemia • Hypercalcemia • Hypomagnesemia • Direct vasodilators ↳ open K+ channels Hypokalemic metabolic alkalosis + Hypomagnesemia |
Osmotic Diuretics | PCT & loop | Solute-free water loss | ㅤ |
Potassium-Sparing Diuretics | ㅤ | ㅤ | ㅤ |
Spironolactone/ Eplerenone: | CD | Block aldosterone. | • Hyponatremia • Hyperkalemia • Gynecomastia |
Amiloride | CD | Blocks ENaC (Liddle syndrome) ↳ SCNN1B/G genes ↳ AD inheritance ↳ Little Hypertensive | • Hyponatremia • Hyperkalemia • Alkalosis + HTN |
Mnemonic: FABulous Glittering Liquid
- Gordon
- Opp of Gitelman
- Psudo-hypoaldosteronism
- Opp to Liddle
Fanconi Syndrome
- Genetic Associations:
- Cystinosis (AR, CTNS gene)
- Lowe syndrome (OCRL gene)
- Defect:
- Type 2 RTA (PCT dysfunction)
- Urinary pH < 5.5
- Hypokalemia
- Pathophysiology:
- ↓ Reabsorption of
- HCO₃⁻ → NAGMA
- Glucose → Glycosuria
- Amino acids → Aminoaciduria
- Phosphate → Phosphaturia
Cystinosis
- Kidney (Fanconi → Polyurea) + Eye (shimmery cystine crystals + Photophobia)
- A lysosomal storage disorder.
- Caused by defective efflux of Cysteine from lysosomes.
- Cysteine accumulates in lysosomes → Lysosomal degranulation →
- Acidic pH is released into tissues
- Leads to tissue degradation.
- Damage to the PCT causes
- Fanconi syndrome
- Glycosuria, aminoaciduria, phosphaturia.
- Bicarbonaturia, polyuria, polydipsia.
- Local tissue damage in the iris causes:
- Iris depigmentation.
- Photophobia.
- Slit lamp
- shimmery cystine crystals in cornea.
- Rx:
- Cysteamine
NOTE: Different Fanconis
ㅤ | ㅤ |
Fanconi disease/syndrome | • Proximal tubular reabsorption problem → Type 2 RTA • Glycosuria, aminoaciduria |
Fanconi anemia (Not syndrome) | • Pancytopenia + radial ray |
Fanconi Bickel syndrome | • Mutation in GLUT-2 • Bickel → Bi → 2 (GLUT 2) Defect in glucose sensing → ↓ insulin release • Postprandial Hyperglycemia. • Fasting Hypoglycemia • Glycogen accumulation disorder |
Holt - Oram (ASD + Radial Ray)
TAR (thrombocytopenia + absent radius)
Congenital torticollis → Cock robin position
Stranger things characters
- Dustin (Cleido cranial dysplasia)
- Robin (Cock robin position)
- Ray (Radial Ray) Hopper (Holt Oram ASD)
Bartter Syndrome
- AR inheritance
- Defect:
- Na⁺-K⁺-2Cl⁻ cotransporter (TAL of LoH) OR
- Barttin channel
- Consequences:
- Polyuria, salt wasting
- ↑Ca²⁺ excretion → Nephrocalcinosis
- Activation of RAAS →↑ Na+, H2O reabsorption → Normal/low BP
- Hypokalemic hypochloremic metabolic alkalosis
Gitelman Syndrome
- AR inheritance
- Defect: Na⁺-Cl⁻ cotransporter (DCT)
- Consequences:
- ↑ Na⁺, Cl⁻, Mg²⁺ excretion
- Hypokalemia, metabolic alkalosis
- Hypomagnesemia
- Onset: Older child
Liddle Syndrome
- AD inheritance
- Defect: ENaC channel (SCNN1B/G genes)
- Consequences:
- ↑ Na⁺ reabsorption → Hypertension
- ↓ Aldosterone → Pseudoaldosteronism
- Hypokalemic metabolic alkalosis
- NOTE:
- Conns
- Hyperaldosteronism
- ↓↓ Plasma renin aldosterone ratio
SAME (Syndrome of Apparent Mineralocorticoid Excess)
Feature | Normal Physiology | SAME |
11 β-HSD type 2 enzyme | Active | ⛔ by Glycyrrhetinic acid (from Licorice consumption) |
Cortisol Conversion | Cortisol → Inactive cortisol | not converted → remains active |
Cortisol binding to mR | Prevented | Unopposed binding (due to enzyme inhibition) |
Resulting Mineralocorticoid Action | Normal | Increased (apparent excess) |
Made with Bullet