Osmotic diuretics. Diuretic drugs: list and characteristics

What are diuretics is often asked by the doctor. Diuretics are diuretics with a different mechanism of action that have a pronounced diuretic effect. Unfortunately, all of them have side effects and their use without a doctor's recommendation is dangerous to health. What are diuretics?

Classification - types of diuretics

Modern diuretic diuretics are one of the greatest advances in internal medicine in the last 25 years. In nephrological practice, the following 4 groups of diuretics are used:

1. thiazide diuretics (benzothiazidine derivatives - thiazides);
2. loop diuretics - furosemide and ethacrynic acid;
3. potassium-sparing diuretics;
4. osmotic diuretics.

Some classic diuretics are never used in kidney disease because of nephrotoxicity (mercury diuretics) or because of inefficiency (theophylline, ammonium chloride).

Thiazide diuretics

The thiazide group of diuretics - hypothiazide (dichlorthiazide, hydrochlorothiazide), cyclomethiazide and others inhibit sodium reabsorption in the cortical nephron loop, and also partially in the distal part of the convoluted tubules. The diuretic effect develops within 1-2 hours, lasts 10-12 hours or more, so it is better to take the drug in the morning. Hypothiazide is prescribed 25 - 100 mg (1 - 4 tablets) / day, cyclomethiazide - 0.5 - 1.5 mg (1 - 3 tablets) / day. The thiazide group also includes brinaldix (take 20-60 mg per day), chlorthalidone (take 25-100 mg in the morning on an empty stomach; has a long-term effect), renez (prescribe 0.5-2 milligrams).

The saluretic effect of this group of diuretics is moderate, about 10% of filtered sodium is released. However, despite the moderation of the diuretic effect, the drugs are widely used, as they are easy to use, have a hypotensive effect, and also improve the course of nephrogenic diabetes insipidus and idiopathic hypercalciuria.

Localization of the action of diuretic drugs in the nephron

Side effects of thiazide diuretics:

• 1. Increase the excretion of potassium with the development of hypokalemia, sometimes metabolic alkalosis, increase the excretion of magnesium
• 2. Reduce the excretion of calcium in the urine - increase its content in the serum (this is the basis for their use for the treatment of idiopathic hypercalciuria).
• 3. Reduce (reversibly) the excretion of uric acid with the development of hyperuricemia.
• 4. Disrupt carbohydrate metabolism, leading to hyperglycemia, as well as worsening the course of diabetes mellitus (why their use for diabetic nephropathy is limited). May worsen renal failure, therefore, in severe chronic renal failure, the use of these drugs is contraindicated. Side effects of the diuretic include cases of pancreatitis, allergic reactions with photosensitivity or necrotizing angiitis.

Loop diuretics

Furosemide has a depressing effect on the active reabsorption of chlorine, acts mainly in the ascending part of the nephron loop, and also (in large doses) in the proximal tubules. It has a quick, short-term and pronounced diuretic effect, 20-30% of the filtered sodium is excreted in the urine. Even when taking the drug inside, it is absorbed quickly and completely. The diuretic effect begins less than 1 hour after ingestion, quickly (in 15–20 minutes) reaches a maximum and lasts for 4 hours. After intravenous administration, the diuretic effect is noted within a few minutes and disappears after 2 hours. a loop diuretic is also used in acute tubular necrosis to prevent (or mitigate) anuria.

When taking the drug inside, the initial dose is 20-40, the maximum is 400-600 milligrams, with intravenous administration of the dose, the drugs range from 20 to 1200 milligrams. Unlike thiazides, furosemide slightly increases glomerular filtration, and therefore is the drug of choice for renal failure.

The diuretic is usually well tolerated. With prolonged use, hyperuricemia can develop up to acute gout, deafness (especially when taking antibiotics at the same time), thrombocytopenia. Hyperglycemic effect is negligible. Very rarely (while taking antibiotics from the cephalosporin group), deterioration in kidney function is possible. Unlike thiazides, it can cause excessive loss of sodium chloride with the development of hyponatremia.

Ethacrynic acid(uregit) is another loop diuretic that works in the same way as furosemide, despite having a different chemical structure. The peak of diuresis occurs 2 hours after taking the drug inside, the diuretic effect stops after 6-9 hours. Assign inside, starting with 50 milligrams (1 tablet), increasing the daily dose to 200 mg if necessary. Take the drug after a meal.

A side effect of a diuretic is hyperuricemia. In rare cases, deafness develops, very rarely irreversible (especially when taking the drug along with antibiotics).

Potassium-sparing diuretics

This group primarily includes spironolactones (aldactone, veroshpiron) - synthetic steroids, competitive aldosterone antagonists. These drugs act at the level of the distal tubules (and possibly the collecting ducts); the action at the level of the proximal tubules is not excluded. IN last years a direct inhibitory effect of spironolactones on the secretion of aldosterone by the adrenal glands has also been shown. Despite the fact that the diuretic effect of spironolactones is weaker than that of thiazides (they release only about 2% of the sodium filtered in the glomeruli), they are widely used, potentiating the effect of agents with a more proximal effect, inhibiting the reabsorption of sodium that has passed (under the influence of hypothiazide, furosemide) proximal tubules .

With isolated use against the background of a normal salt regime, potassium-sparing diuretics do not work, the effect is noted only if sodium is limited.

The diuretic effect of drugs begins after a few days. The features include a decrease in potassium reabsorption (why the appointment together with proximal diuretics, especially with thiazides, is advisable not only to potentiate the effect, but also because of the opposite effect on potassium excretion).

The daily dose of veroshpiron ranges from 25 to 200 - 300 milligrams.

Side effect: hyperkalemia, rarely drowsiness, hirsutism, gynecomastia, menstrual irregularities. Veroshpiron is not recommended for patients with severe renal insufficiency (especially with diabetic nephropathy).

Triamterene also has a potassium-sparing property (a drug with a completely different mechanism of action, not related to the inhibition of aldosterone). Acts in the area of ​​the distal tubules, rapidly inhibiting sodium transport. The diuretic ability is weaker than that of thiazides, and stops after 10 hours.

It is prescribed at a dose of 50-300 milligrams, usually 200 mg in 1-2 doses (after breakfast and lunch), more often used in combination with stronger diuretics, side effects of the diuretic include uric acid retention, sometimes hyperglycemia.

The drug amiloride, administered at a dose of 5–20 mg per day, is similar in structure and mechanism. When taking 5 milligrams of amiloride, more potassium is stored in the body than when 5 g of potassium chloride is taken orally.

Osmotic diuretics

Osmotic diuretics- These are non-metabolized and non-absorbable substances in the kidneys that are filtered in the glomeruli, increase the osmolarity of glomerular urine and thereby reduce tubular reabsorption.

Mannitol has found the greatest use in nephrology, but more often not for nephrotic syndrome, but for the prevention of acute renal failure or in the early stages of its development, as well as for the creation of forced diuresis in conditions that threaten the development of acute tubular necrosis. Mannitol is administered slowly intravenously in the form of a 10-20% solution at a rate of 0.5-1 g/kg of body weight.

For minor edema, sometimes it is enough to recommend treatment natural remedies- infusions and decoctions medicinal plants with diuretic properties (bearberry, juniper, parsley, lingonberries).

Diuretics optimal combinations

Since the mechanism of action of different groups of diuretics is not the same, if one agent is ineffective, it should be replaced by another or combined. We can recommend the following optimal combinations and treatment regimens.

Saluretics of proximal action should be combined with distal potassium-sparing agents. The combination with veroshpiron (or triamterene) is especially important when prescribing thiazides. There are official combinations of drugs, including saluretics and potassium-sparing diuretics: triampur (the tablet contains 25 mg of triamterene and 12.5 mg of hypothiazide), furesis (the tablet contains 50 mg of triamterene and 40 mg of furosemide). You can combine drugs and close action. So, furosemide, introduced during the period of maximum diuresis caused by thiazides, increases diuresis (at the same time, thiazides do not increase diuresis caused by furosemide). Thiazides can enhance the effectiveness of ethacrynic acid - furosemide does not have this property).

Euphyllin with slow intravenous administration can enhance the effect of natriuretics when administered at the height of the peak diuresis (for example, 30 minutes after taking furosemide or ethacrynic acid).

It is necessary to remember some dangerous combinations diuretics with other drugs. The combination of ethacrynic acid or furosemide with kanamycin, gentamicin, streptomycin can lead to deafness. The combination of ethacrynic acid or furosemide with cephaloridine is nephrotoxic. When diuretics are combined with acetylsalicylic acid, its secretion by the kidneys is impaired. If you combine diuretics and calcium supplements at the same time, hypercalcemia may develop.

• 1) to reduce the loss of potassium in the urine, treatment should begin with veroshpiron or triamteren;
• 2) after 2-3 days, add thiazide diuretics;
• 3) in case of inefficiency, replace thiazides with furosemide or ethacrynic acid. Double the dose of furosemide every day until diuresis occurs or until a dose of 4000 milligrams per day is reached;
• 4) if diuresis does not occur, continue taking furosemide (part of the dose administered intravenously), while increasing blood volume by intravenous administration of albumin or salt-free dextran. The effect is even more likely if mannitol is given intravenously at the same time. The patient must be weighed daily. This gives a much better indication of fluid balance than measuring diuresis and fluid intake.

With the disappearance of edema, diuretics are canceled.

Treatment with diuretics

• When treating with the use of diuretics, the following provisions should be borne in mind (partially we have already mentioned them).
• These drugs can lead to hypokalemia and metabolic alkalosis. If a loop diuretic is prescribed, potassium preparations must be additionally used. Hypothiazide and furosemide in the outpatient setting are prescribed intermittent courses (for example, 2 days a week or every other day).
• Diuretic drugs can lead to a dramatic loss of sodium chloride and a decrease in CBV with a resulting decrease in proximal reabsorption. Diuretics, reducing BCC, lead to an increase in the level of renin and aldosterone.
• With severe refractoriness of edema, causing pain and very unpleasant sensations to the patient, in extreme cases, such old measures as taking laxatives (30 g of magnesium sulfate, sorbitol) and puncturing the skin with sterile thick needles can be recommended. In the same situations, ultrafiltration is possible (with an assessment of the risk of a subsequent decrease in CF).
• In severe hyperaldosteronism, oral potassium intake without the addition of veroshpiron does not affect hypokalemia.
• Patients with prolonged refractory edema who take diuretics for a long time often develop hyponatremia (the content of total sodium in the body may be increased). A decrease in sodium levels is combined with peripheral vascular insufficiency (hypovolemic shock), secondary hyperaldosteronism, a decrease in potassium, alkalosis, a decrease in CF, and an increase in urea concentration.
• With CF less than 20 ml / min, furosemide is the drug of choice, which allows you to increase the intake of table salt (sodium chloride), possibly increasing CF. Veroshpiron and triamteren should not be prescribed because of the risk of hyperkalemia.
• When treating patients with chronic renal failure, it should be remembered that fluid loss with a subsequent decrease in BCC can lead to a further deterioration in kidney function. Electrolyte disturbances occur more easily - hyperkalemia, hypochloremia, alkalosis, hypercalcemia, as well as hyperuricemia and hyperglycemia. When taking large doses of furosemide and ethacrynic acid, hearing loss (usually transient) may occur.

Drugs that speed up the excretion of urine from the body are called diuretics. These drugs reduce the ability of the kidneys to reabsorb electrolytes, against the background of an increasing concentration of which fluid is released.

Mercury was the first diuretic used by man. In the 19th century, this substance was used in the treatment of syphilis. It turned out to be practically powerless in front of this disease, but the diuretic effect of mercury did not escape the attention of physicians. Later, safer compounds appeared, the improvement of which made it possible to obtain effective and non-toxic diuretics.

Taking diuretics helps:

• elimination of puffiness in heart and vascular insufficiency;
• lowering blood pressure in hypertension;
• alleviate symptoms of kidney disease;
• removal of toxins during intoxication.

Puffiness is a frequent companion of diseases of the urinary and vascular systems, the heart. Pathology develops as a result of sodium retention in the body. Diuretics help to remove its excess. Due to this, swelling is noticeably reduced.

Hypotension (high blood pressure) against the background of increased sodium negatively affects blood vessels. They shrink and shrink. Diuretics, used as blood pressure lowering drugs, not only wash out sodium, but also expand the walls of blood vessels. This action of the drug and leads to a decrease in pressure.

The elimination of toxins through the use of diuretics is called "forced diuresis" in clinical medicine. This method consists in the fact that after intravenous administration of solutions to the patient, a certain dose of a highly effective diuretic drug is administered in a similar way. This leads to the fact that toxic substances are washed out of the body simultaneously with the liquid.

There are several types of diuretic drugs that differ in the mechanism of action used in the treatment of various pathologies.

Diuretics are of three types:

1. Affecting the functioning of the epithelial tissue of the renal tubules. These drugs include the following: Triamterene, Hydrochlorothiazide, Bumetanide, Cyclomethiazide, Chlorthalidone, Bendroflumethiazide, Ethacrynic acid, Clopamid, Meticlothiazide, Amiloride, Metolazone, Furosemide, Indapamide, Torasemide.
2. Calcium-sparing, related to aldosterone (mineralocorticoid) receptor antagonists. This type of diuretic includes Spironolactone, which is known under such a trade name as Veroshpiron.
3. Osmotic eg Mannitol (Monitol).

Diuretics are classified not only by the mechanism of action, but also by the degree of sodium leaching:

• highly effective (washing out over 15%);
• average efficiency (10%);
• ineffective (5%).

How diuretics work

The effectiveness of diuretics in hypotension is directly related to the fact that they reduce sodium levels and dilate blood vessels. Maintaining vascular tone and lowering the concentration of fluid allows you to stop arterial hypertension.

Taking diuretics relaxes myocardial cells, reduces platelet adhesion, improves microcirculation in the kidneys, and reduces the load on the left ventricle of the heart muscle. This mechanism of action leads to the fact that the myocardium needs much less oxygen. Osmotic diuretics, in addition to their intended purpose, increase the level of osmolar pressure growth medium cellular elements - interstitial fluid.

The antispasmodic effect of drugs is based on the ability to relax the smooth muscles of the arteries, biliary tract, and bronchi.

The desire to get rid of hated kilograms pushes people to rather dubious experiments. This fate befell diuretic drugs. Many mistakenly believe that these drugs help to lose weight. This misconception is caused by the fact that ninety percent of adipose tissue is water.

Diuretics have an anti-atherogenic effect. It lies in the ability to destroy cholesterol plaques. A drug such as Indapamide lowers the level of bad cholesterol in the blood. This in no way means that taking diuretics will get rid of fat. It stays in place, only the liquid comes out. The positive effect of the drug is that it reduces the risk of stroke, atherosclerosis, heart failure.

Diuretics have an effect on various systems, but to a greater extent on the urinary. If medicines are taken exclusively for their intended purpose, they normalize the balance of water and electrolytes. Uncontrolled use of diuretics, on the contrary, leads to numerous health problems, even death is possible.

The withdrawal of fluid from the body is impossible without the loss of ions. The latter regulate the work of each internal organ. Therefore, weight loss does not occur as a result of a decrease in body fat, but due to dehydration, which is accompanied by ionic imbalance. Against this background, cardiac arrhythmia, hypotension develops, vision decreases, it is felt general state weakness, dizzy spells. With a strong overdose, hallucinations and collapse are possible.

Those who wish to use a diuretic for the purpose of losing weight must remember that these drugs are included in the category prohibited for athletes. The reason for this was the death of an athlete who abused diuretics to get relief muscles. Only people who are far from medicine can recommend these drugs for weight loss.

Indications for the use of diuretics

Diuretic drugs are prescribed for those suffering from arterial hypertension, which is especially acute in old age, with an excess of sodium due to the retention and accumulation of this substance in the body. The latter condition is observed in chronic heart and kidney failure, ascites. Osteoporosis sufferers are recommended to take thiazides, people with congenital Liddle's syndrome - potassium-sparing diuretics, from cardiac edema, glaucoma, intraocular pressure, cirrhosis - drugs that affect the functioning of the kidneys.

Diuretic thiazide-like drugs are indicated in the treatment and prevention of arterial hypotension. When moderately high blood pressure take small doses. Prophylactic use of these drugs reduces the risk of stroke. Unless necessary, taking large doses of these drugs is not recommended. This can lead to the development of hypokalemia. To prevent a drop in the level of potassium in the blood, thiazide diuretics are combined with taking potassium-sparing ones.

Therapy with diuretics is active and supportive. With active treatment with diuretics, patients are prescribed moderate dosages of potent drugs, for example, Furosemide, and with maintenance, regular intake of drugs with a diuretic effect.

Contraindications to taking diuretics

Contraindications to the appointment of diuretics are:

• hypokalemia;
• diabetes;
• renal and respiratory failure;
• decompensated cirrhosis.

These drugs should not be taken by patients with individual intolerance to sulfanidamide derivatives. Drugs of the thiazide group, for example, Meticlothiazide, Bendroflumethiazide, Cyclomethiazide, Hydrochlorothiazide, can cause a sharp rise in blood sugar levels.

In patients suffering from ventricular arrhythmia, taking diuretics can cause a deterioration in the condition, and is strictly under medical supervision. The combination of diuretic therapy with the use of lithium salts and cardiac glycosides requires maximum caution. Patients with heart failure are not prescribed diuretics of the osmotic group.

Side effects and health risks

Thiazide drugs can increase uric acid in the blood. This side effect of using medicines this group should be taken into account in patients with gout. The use of thiazides in this pathology can lead to an exacerbation of the disease, worsen the patient's condition.

Diuretics of average efficiency, for example, Hydrochlorothiazide or Hypothiazide, require a strict dosage. If the dose is calculated incorrectly, the patient may feel nausea, weakness, increased drowsiness, headache, dry mouth. An overdose may be accompanied by diarrhea. Similar symptoms are observed with individual intolerance to the drug. Against the background of an imbalance of ions, muscle weakness, spasms of skeletal muscles, arrhythmia, allergies develop, an increase in sugar and a decrease in male libido can be observed.

Furosemide may have the following side effects: reduce magnesium, calcium, potassium, cause nausea, frequent urination, dizziness, dry the oral mucosa. Violations in ion exchange provoke an increase in glucose, uric acid, calcium. The high content of these substances adversely affects hearing, manifested by paresthesia, skin rashes.

Uregit- a drug with an increased irritant effect. Its reception can adversely affect hearing.

Aldosterone antagonists can cause convulsions, diarrhea, vomiting, rashes on the skin, gynecomastia. The misappointment of these medications causes menstrual irregularities in women, and threatens with impotence for men.

Osmotic drugs with the wrong approach to the treatment of heart failure can increase the load on the heart muscle by increasing plasma volumes. This side effect leads to pulmonary edema.

Popular diuretics: how they affect the body

Drugs, the pharmacological action of which is directed to the renal tubules, excrete sodium along with urine.

Diuretics from the thiazide-like group, for example, Meticlothiazide, reduce the degree of absorption of not only sodium, but also chlorine. These drugs can often be found under the general name "saluretics", which they received from English word"salt", meaning "salt".

Diuretic with average efficiency, which promote the excretion of sodium, are prescribed, as a rule, for edema and kidney disease, to patients with heart failure. Hypothiazide is most often used as an antihypertensive agent. This is due to the fact that this medication flushes out excess sodium, stabilizes high blood pressure. These drugs increase the effect of hypertensive drugs.

To avoid affecting blood pressure, these diuretics are taken in large rather than moderate doses. The active substances present in the composition of Hypothiazide lower the level of calcium ions and prevent the accumulation of salts in the kidneys. It is often prescribed in the treatment of diabetes insipidus, urolithiasis.

Indapamide(known under the trade name as Arifon) is a drug that differs from other diuretics in its ability to dilate blood vessels and relieve spasms.

Furosemide(trade name Lasix) is the most effective diuretic, starting to act within ten minutes after intravenous administration. It is prescribed to patients with arterial hypotension, peripheral edema, left ventricular acute failure with pulmonary edema, in order to remove toxins from the body. A diuretic such as Uregit has similar pharmacological properties. The difference is that it lasts longer.

Competitive aldosterone antagonists, known under the trade names Aldactone or Veroshpiron, are diuretics, the action of which is based on the reduction of potassium and magnesium ions, preventing the absorption of sodium ions. Indications for the appointment of diuretics from this group are: hypertension, edema, congestive processes against the background of acute or chronic disorders of the heart muscle.

Osmotic diuretics have low permeability through membranes. The most common and effective drug This group of diuretics is Monitol administered intravenously. It reduces intracranial and intraocular, but increases plasma osmotic pressure. It is prescribed to patients with oliguria, against which severe blood loss, trauma, burns occur, with cerebral edema, glaucoma, including during the rehabilitation period after glaucoma surgery.

Diuretics of natural origin

There are many natural diuretics that are inferior in action to artificial counterparts, but were used by humans long before the advent of synthetic diuretics. Lower efficiency folk methods offset by harmlessness and softness. Properly selected dosage allows you to use decoctions for quite a long time without any side effects and harm. It is necessary to take natural diuretics, as well as synthetic drugs, only after finding out true reason why fluid is retained in the body.

If fluid retention is caused by swelling and malfunctioning of the heart, they drink a decoction made from birch leaves or strawberries. Birch leaves are used as compresses for swelling of the upper and lower extremities. inflammation Bladder and kidneys are treated with tansy, lingonberries, shepherd's purse. Flaxseeds, bearberry, wild rose, orthosiphon are most often used in the treatment of puffiness. Rosehip tea is taken during long-term antibiotic treatment and recovery after surgery.

Orthosiphon is a traditional kidney tea that has both a diuretic and an antispasmodic, anti-inflammatory effect. Natural diuretics are not only herbs, but also other vegetable crops. The removal of fluid is facilitated by the use of pumpkin, melons, celery, parsley. Instead of fresh herbs, you can use cucumber and dandelion leaves to make a salad that reduces puffiness.

Taking diuretics during pregnancy and lactation

Many expectant mothers, especially on recent months pregnancy, edema. They appear as a result of the growing uterus compressing the vena cava. Puffiness cannot be ignored. It can signal the development of pathological conditions such as renal failure and preeclampsia. When compliance diet food does not bring a visible result, a pregnant woman is prescribed synthetic or natural diuretics.

Most diuretics are contraindicated at any stage of pregnancy. Take medicinal diuretics only as prescribed by a doctor and with extreme caution. In the early stages, almost all drugs are prohibited, and in the later stages only a few are allowed, which are prescribed by a specialist. An incorrectly selected diuretic or dosage can change the composition of the blood, give rise to problems with the kidneys, hearing, vision, and even lead to a disease such as jaundice.

They can even harm a pregnant woman and fetus folk remedies. Regular use of herbal preparations violates the electrolyte balance, negatively affects further pregnancy. You can not take juniper, strawberries, parsley root. The safest remedy is orthosiphon. It can be used both during pregnancy and lactation.

If it is impossible to do without taking diuretic drugs, the attending physician prescribes Kanefron tablets. This medicine can be drunk at almost any stage of pregnancy. Drops of this drug are not prescribed, as they contain alcohol. If the swelling occurs without acute inflammatory processes in the kidneys, a herbal remedy such as Phytolysin can be prescribed.

An alternative to diuretics can be the bronchodilator Eufillin, which has a diuretic effect. It is contraindicated in women suffering from hypotension, epileptic seizures, with a diseased heart. By prescribing it during lactation, the specialist assesses the risk and the real need for taking this drug.

The mechanism of action of osmotic diuretics is reduced to a decrease in plasma pressure, which promotes the removal of water from edematous tissue and increases the circulating blood volume. As a result of the described impact, there is an increase in blood flow in the glomeruli of the kidneys, which increases filtration in them. In contrast to this, the functioning of the countercurrent - rotary system in the loop of Henle is disrupted. This means that in the loop of Henle (in the ascending knee) the passive reabsorption of chlorine and sodium will decrease.

Due to poor reabsorption of osmotic diuretics, their concentration in the urine increases as they go deeper into the tubule, the reabsorption of sodium and water ions is delayed, the concentration function of the nephron is disturbed, and the removal of water and sodium from the patient's body increases.

As a reaction to this, in the right atrium and liver, special cells increase the production of natriuretic factor, aldosterone secretion decreases, and sodium reabsorption in the far nephron is disturbed.

Drugs related to osmotic diuretics

The list of osmotic drugs is reduced to Urea, Mannitol and Sorbitol. Of all these drugs, Mannitol is most often prescribed, since Sorbitol and Urea have a shorter duration of exposure and have a weak effect. In addition, Urea is contraindicated in patients with impaired liver and kidney function. However, all three drugs have the same mechanism of action, aimed at increasing blood pressure and diuresis.

The mechanism of taking osmotic diuretics requires certain skills, since they must be slowly administered intravenously, but not drip. Inside a person, these drugs behave differently:

• Mannitol, which penetrates into tissue cells by no more than 10%, almost all remains in the bloodstream;
• Sorbitol quickly penetrates the tissues and turns into glycogen (which reduces its effect);
• Urea, slowly transforming, increases the osmotic pressure in edematous tissues and attracts fluid from the bloodstream (rebound effect).

The mechanism of action of osmotic diuretics on the body leads not only to a decrease in pressure, swelling of brain tissues, edema of the lungs, larynx, with glaucoma, drug poisoning, osteomyelitis, peritonitis, sepsis, burns or after shock, but can cause a number of undesirable effects, such as:

Interesting stuff on this topic!

Diuretic drugs, or diuretics, are heterogeneous in chemical composition drug group. All of them cause a temporary increase in the excretion of water and minerals (mainly sodium ions) from the body through the kidneys. We bring to the attention of the reader a list of diuretic drugs most commonly used in modern medicine, their classification and characteristics.

Diuretics are classified according to their "point of application" in the nephron. The simplified nephron consists of the glomerulus, proximal tubule, loop of Henle, and distal tubule. In the glomerulus of the nephron, water and metabolic products are released from the blood. In the proximal tubule, all the protein released from the blood is reabsorbed. The resulting fluid passes through the proximal tubule into the loop of Henle, where water and ions, in particular sodium, are reabsorbed. In the distal tubule, the reabsorption of water and electrolytes is completed, and hydrogen ions are released. The distal tubules unite into collecting ducts, through which the formed urine is excreted into the pelvis.
Depending on the site of action of diuretics, the following groups of drugs are distinguished:

1. Acting in the glomerular capillaries (eufillin, cardiac glycosides).

2. Acting in the proximal tubule:

• carbonic anhydrase inhibitors (diacarb);
• osmotic diuretics (mannitol, urea).

3. Operating in the loop of Henle:

• throughout: loop diuretics (furosemide);
• in the cortical segment: thiazide and thiazide-like (hypothiazid, indapamide).

4. Acting in the proximal tubule and ascending loop of Henle: uricosuric (indacrinon).

5. Acting in the distal tubule: potassium-sparing:

• competitive aldosterone antagonists (spironolactone, veroshpiron);
• non-competitive aldosterone antagonists (triamterene, amiloride).

6. Acting in the collecting ducts: aquaretics (demeclocycline).

Characteristic

Diuretics acting at the glomerular level

Eufillin dilates the renal vessels and increases blood flow in the tissues of the kidneys. As a result, glomerular filtration and diuresis increase. These drugs are most often used to enhance the effectiveness of other diuretic drugs.

Potassium-sparing drugs

These drugs slightly increase diuresis and excretion of sodium in the urine. Their distinguishing feature is the ability to retain potassium, thereby preventing the development of hypokalemia.

The main drug from this group is spironolactone (veroshpiron). It is prescribed for the prevention and treatment of potassium deficiency that occurs with the use of other diuretics. Spironolactone can be combined with any other diuretic. It is used for hyperaldosteronism and severe hypertension. The use of spironolactone is especially justified in the treatment of chronic heart failure.

Side effects include drowsiness, menstrual irregularities. This remedy has antiandrogenic activity and can cause an increase in the mammary glands in men (gynecomastia).
Potassium-sparing diuretics are contraindicated in severe kidney disease, hyperkalemia, urolithiasis, as well as during pregnancy and lactation.

Aquaretics

Medicines in this group increase the excretion of water. These agents counteract antidiuretic hormone. They are used for cirrhosis of the liver, congestive heart failure, psychogenic polydipsia. The main representative is demeclocycline. Side effects include photosensitivity, fever, nail changes, and eosinophilia. The drug can cause damage to the renal tissue with a decrease in glomerular filtration.

Aquaretics include lithium salts and vasopressin antagonists.

Side effects

Diuretics remove water and salts from the body, changing their balance in the body. They cause the loss of hydrogen, chlorine, bicarbonate ions, leading to acid-base balance disorders. The metabolism changes. Diuretics can also cause damage to internal organs.

Violations of water and electrolyte metabolism

With an overdose of thiazide and loop diuretics, extracellular dehydration may develop. To correct it, it is necessary to cancel diuretics, prescribe water and saline solutions inside.
A decrease in the sodium content in the blood (hyponatremia) develops with the use of diuretics and at the same time following a diet with salt restriction. Clinically, it is manifested by weakness, drowsiness, apathy, decreased diuresis. For treatment, solutions of sodium chloride and soda are used.

A decrease in the concentration of potassium in the blood (hypokalemia) is accompanied by muscle weakness up to paralysis, nausea and vomiting,. This condition occurs predominantly with an overdose of loop diuretics. For correction, a diet with a high content of potassium is prescribed, potassium preparations orally or intravenously. Such a popular remedy as panangin is not able to restore potassium deficiency due to the low content of the trace element.

Elevated blood potassium (hyperkalemia) is observed quite rarely, mainly with an overdose of potassium-sparing drugs. It is manifested by weakness, paresthesia, slowing of the pulse, the development of intracardiac blockades. Treatment consists in the introduction of sodium chloride and the abolition of potassium-sparing drugs.

Reduced magnesium levels in the blood (hypomagnesemia) may be a complication of therapy with thiazide, osmotic and loop diuretics. It is accompanied by convulsions, nausea and vomiting, bronchospasm, and heart rhythm disturbances. Changes are characteristic nervous system: lethargy, disorientation, hallucinations. This condition is more common in older people who abuse alcohol. It is treated by prescribing panangin, potassium-sparing diuretics, and magnesium preparations.

Low blood calcium concentration (hypocalcemia) develops with the use of loop diuretics. It is accompanied by paresthesia of the hands, nose, convulsions, spasm of the bronchi and esophagus. For correction, a diet is prescribed, rich in calcium, and preparations containing this trace element.

Violation of acid-base balance

Metabolic alkalosis is accompanied by "alkalinization" of the internal environment of the body, occurs with an overdose of thiazide and loop diuretics. It is accompanied by indomitable vomiting, convulsions, impaired consciousness. For treatment, ammonium chloride, sodium chloride, calcium chloride are used intravenously.

Metabolic acidosis is an "acidification" of the internal environment of the body, which develops when carbonic anhydrase inhibitors, potassium-sparing agents, osmotic diuretics are taken. With significant acidosis, deep and noisy breathing, vomiting, and lethargy occur. To treat this condition, diuretics are canceled, sodium bicarbonate is prescribed.

Exchange disorders

Violation of protein metabolism is associated with potassium deficiency, leading to a violation of the nitrogen balance. It develops most often in children and the elderly with a low protein diet. To correct this condition, it is necessary to enrich the diet with proteins and prescribe anabolic steroids.

When using thiazide and loop diuretics, the concentration of cholesterol, beta-lipoproteins, and triglycerides in the blood increases. Therefore, when prescribing diuretics, lipids in the diet should be limited, and, if necessary, diuretics should be combined with angiotensin-converting enzyme inhibitors (ACE inhibitors).

Therapy with thiazide diuretics can cause an increase in blood glucose concentration (hyperglycemia), especially in patients with diabetes or obesity. To prevent this condition, a restriction in the diet of easily digestible carbohydrates (sugar), the use of ACE inhibitors and potassium preparations is recommended.

In persons with hypertension and impaired purine metabolism, an increase in the concentration of uric acid in the blood (hyperuricemia) is likely. The likelihood of such a complication is especially high in the treatment of loop and thiazide diuretics. For treatment, a purine-restricted diet, allopurinol, diuretics are combined with ACE inhibitors.

In the case of prolonged use of large doses of diuretics, a violation of kidney function with the development of azotemia (an increase in the concentration of nitrogenous waste products in the blood) is likely. In these cases, it is necessary to regularly monitor the indicators of azotemia.

allergic reactions

Diuretic intolerance is rare. It is most characteristic of thiazide and loop diuretics, mainly in patients allergic to sulfonamides. An allergic reaction may appear skin rash, vasculitis, photosensitivity, fever, impaired liver and kidney function.

Therapy for an allergic reaction is carried out according to the usual scheme with the use of antihistamines and prednisone.

Damage to organs and systems

The use of carbonic anhydrase inhibitors may be accompanied by impaired function of the nervous system. Appear headache, insomnia, paresthesia, drowsiness.

With intravenous administration of ethacrynic acid, toxic damage to the hearing aid can be observed.

Almost all groups of diuretic drugs increase the risk of developing urolithiasis.

Gastrointestinal disorders may occur, manifested by lack of appetite, abdominal pain, nausea and vomiting, constipation or diarrhea. Thiazide and loop diuretics can provoke the development of acute cholecystopancreatitis, intrahepatic cholestasis.

Possible changes in the hematopoietic system: neutropenia, agranulocytosis, autoimmune intravascular hemolysis, hemolytic anemia, lymphadenopathy.

Spironolactone can cause gynecomastia in men and menstrual irregularities in women.
When prescribing large doses of diuretics, blood thickens, as a result, the risk of thromboembolic complications increases.

Interaction with other drugs

Diuretics are often used in conjunction with other drugs. As a result, the effectiveness of these drugs varies, and unwanted effects may occur.

The combined use of thiazide diuretics and cardiac glycosides increases the toxicity of the latter due to hypokalemia. Their simultaneous use with quinidine increases the risk of its toxicity. The combination of thiazide drugs with antihypertensives has an increased hypotensive effect. With their simultaneous appointment with glucocorticosteroids, the likelihood of hyperglycemia is high.

Furosemide increases the ototoxicity of aminoglycosides, increases the risk of developing glycoside intoxication. When loop diuretics are combined with non-steroidal anti-inflammatory drugs, the diuretic effect is weakened.

Spironolactone increases the concentration of cardiac glycosides in the blood, enhances the hypotensive effect of antihypertensive drugs. With the simultaneous appointment of this drug and non-steroidal anti-inflammatory drugs, the diuretic effect is reduced.
Uregit causes increased toxicity of aminoglycosides and tseporin.

The combination of thiazide and loop diuretics and ACE inhibitors leads to an increase in the diuretic effect.

Principles of rational therapy with diuretics

Diuretics should only be used when edema occurs. With a slight edematous syndrome, diuretics of plant origin (infusion of birch leaves, lingonberries, decoction of horsetail, diuretic collection), grape juice, apples and watermelons can be used.

Treatment should begin with small doses of thiazide or thiazide-like diuretics. If necessary, potassium-sparing drugs are added to therapy, and then loop agents. With an increase in the severity of the edematous syndrome, the number of combined diuretics and their dosage increases.

It is necessary to choose the dosage in such a way that diuresis per day does not exceed 2500 ml.
Thiazide, thiazide-like and potassium-sparing drugs are preferably taken in the morning on an empty stomach. The daily dosage of loop diuretics is usually administered in two divided doses, for example, at 8 am and 2 pm. Spironolactone can be taken once or twice a day, regardless of meals and time of day.
In the first stage of treatment, diuretics should be taken daily. Only with a steady improvement in well-being, a decrease in shortness of breath and swelling, can they be used intermittently, only a few days a week.

Therapy of edema against the background of chronic heart failure must be supplemented, which significantly improves the effect of diuretics.

TV channel "Russia-1", program "About the most important" on the topic "Diuretics"

One of the most common pharmacological groups of medicines are diuretics or diuretics. Means are widely used both for the treatment of chronic pathologies and for the relief of acute conditions (for example, pulmonary edema, brain). There are several groups of drugs that differ in strength and mechanism of pharmacological action. Familiarize yourself with the indications and contraindications of diuretics.

Diuretics

Diuretic drugs or diuretics are medicines that increase the rate of blood filtration by the kidneys, thereby removing excess fluid, lowering blood pressure, and accelerating the removal of toxic substances from the body. Depending on the localization of action, the following types of diuretics are distinguished: extrarenal and renal (loop, acting on the proximal or distal tubules of the nephron).

After taking diuretics in the body, blood pressure decreases, the absorption of water, electrolytes in the renal tubules increases, the rate of urine excretion from the body increases. Under the influence of drugs in the blood, the concentration of potassium and sodium decreases, which can adversely affect the patient's well-being: convulsive syndrome, tachycardia, loss of consciousness, etc. often develop, so the regimen and dosage of the medication should be strictly observed.

Classification of diuretics

Each representative of diuretics has its own characteristics of exposure, contraindications and side effects. The use of potent compounds provokes the active excretion of important electrolytes, rapid dehydration, headaches, hypotension. Urinary agents are classified according to the mechanism and localization of action:

1. Loopback.
2. Thiazide and thiazide-like.
3. carbonic anhydrase inhibitors.
4. Potassium-sparing (aldosterone antagonists and non-adolsterones).
5. Osmodiuretics.

Loopback

The mechanism of action of loop diuretics is due to the relaxation of the muscles of the vessels, the acceleration of blood flow in the kidneys by increasing the synthesis of prostaglandins in endothelial cells. Loop diuretics begin to act after approximately 20-30 minutes when administered orally and after 3-5 minutes when administered parenterally. This property allows the use of drugs of this group in life-threatening conditions. Loop diuretics include:

• Furosemide;
• ethacrynic acid;
• Britomar.

Thiazide

Diuretic drugs of the thiazide series are considered to be of moderate impact, their effect occurs after about 1-3 hours and lasts throughout the day. The mechanism of action of such medicines is directed to the near tubules of the nephron, due to which the reverse absorption of chlorine and sodium occurs. Besides, thiazide drugs increase the excretion of potassium, retain uric acid. Side effects that are observed as a result of taking these drugs are expressed in metabolic disorders and osmotic pressure.

Thiazide drugs are prescribed to eliminate edema with high blood pressure, heart failure. It is not recommended to use diuretics in diseases of the joints, pregnancy, breastfeeding. Among the thiazide drugs are:

• Diuril;
• Dichlothiazide;
• Chlortalidone.

Potassium-sparing

This type of diuretic drugs reduces systolic blood pressure, reduces tissue swelling, and increases the concentration of potassium in the blood. The diuretic effect of potassium-sparing drugs is weak, since little sodium is reabsorbed in the distal nephron of the kidney. Medicines This group is subdivided into sodium channel blockers and aldosterone antagonists. Indications for the use of potassium-sparing drugs are:

• tumor of the adrenal cortex;
• arterial hypertension;
• potassium deficiency;
• lithium poisoning;
• the need to normalize eye pressure in glaucoma;
• increased intracranial pressure;
• diastolic and systolic heart failure.

Among the contraindications to the use of potassium-sparing drugs are Addison's disease, hyponatremia, hyperkalemia, menstrual irregularities. With prolonged use of this group of drugs, the development of hyperkalemia, diseases of the gastrointestinal tract, paralysis, and impaired skeletal muscle tone is possible. Among the most popular potassium-sparing drugs are:

• Veroshpiron;
• Triamterene;
• Amiloride;
• Diazide;
• Moduretic.

Herbal diuretics

To reduce edema, which is not a consequence of chronic diseases, but is caused by excessive consumption of salty foods, it is recommended to use natural diuretics. Such funds have a number of advantages:

• have a significant diuretic effect;
• suitable for long-term use;
• do not cause renal and extrarenal side effects;
• suitable for use by children, pregnant women;
• well combined with other medicines.

Some drugs related to diuretics are of natural origin. Herbal diuretics include many herbs, as well as some fruits and vegetables. Here are some examples of such natural remedies:

• strawberry;
• yarrow herb;
• chicory root;
• leaves, birch buds;
• lingonberry leaves;
• rose hip;
• watermelons;
• cucumbers.

Indications for the use of diuretics

Diuretic pharmacological agents prescribed for pathologies that are accompanied by fluid retention, a strong increase in blood pressure, intoxication. These states include:

• chronic renal failure;
• heart failure;
• hypertensive crises;
• glaucoma;
• violations of the functioning of the liver;
• excess synthesis of aldosterone.

For hypertension

Arterial hypertension uncomplicated by renal insufficiency can be treated with diuretics. The drugs reduce the volume of circulating blood and systolic output, due to which the pressure decreases gradually. Long-term therapy leads to a decrease in the diuretic effect, stabilization of blood pressure with the help of its own compensatory mechanisms (increase in the content of the hormones aldosterone, renin). With arterial hypertension appoint:

1. Hydrochlorothiazide. The active substance is hydrochlorothiazide. The drug belongs to the group of thiazide diuretics of medium strength. Depending on the clinical picture, 25-150 mg per day is prescribed. The action of Hydrochlorothiazide occurs within an hour and lasts about a day. The drug is suitable for long-term use and prevention of hypertensive crises.
2. Chlortalidone. A drug of the thiazine-like group, the active ingredient is chlorthalidone. Chlortalidone begins to act 40 minutes after ingestion, the duration of the effect is 2-3 days. Assign a remedy of 25-100 mg in the morning, before meals. The disadvantage of chlorthalidone is the frequent development of hypokalemia.
3. Indapamide. This diuretic is a thiazide-like diuretic that increases the excretion of sodium, potassium, and chlorine. The effect of the drug occurs after 1-2 hours and continues throughout the day.

With intoxication

In severe poisoning resort to forced diuresis with the help of diuretics to remove toxins and poisons from the blood. Diuretics are used for intoxication with water-soluble substances, which include:

• alcohol;
• heavy metal salts;
• narcotic substances;
• inhibitory substances;
• strong drugs (barbiturates).

Forced diuresis is performed in stationary conditions. At the same time, hydration and dehydration are performed simultaneously with minimal changes in the composition and amount of blood. Diuretics help to achieve an increase in the filtration capacity of nephrons for the rapid, efficient removal of toxic substances. To perform forced diuresis use:

1. Furosemide. The medicine has a quick, but short-lived diuretic effect. For forced diuresis, a 1% solution is prescribed in an amount of 8-20 ml parenterally. The action of the drug begins after 5-7 minutes and lasts 6-8 hours.
2. Ethacrynic acid. It has somewhat less activity than Furosemide. In case of intoxication, parenteral administration of 20-30 ml of the solution is indicated. The action of Ethacrynic acid begins after 30 minutes, lasts 6-8 hours.

For diseases of the cardiovascular system

Diuretics are prescribed for chronic heart failure to eliminate edema. As a rule, the minimum dosages of drugs are shown. Therapy for heart failure is recommended to start with thiazide or thiazide-like diuretics:

1. Clopamid. The drug has a pronounced natriuretic effect. For heart disease, a dosage of 10-40 mg daily in the morning before meals is indicated. Clopamid begins to act after 1-2 hours, the duration of the effect persists for a day.
2. Diuver. Loop diuretic, the active substance is torasemide. The drug inhibits the reabsorption of sodium and water ions. The effect of the drug reaches a maximum after 2-3 hours after ingestion, the diuretic effect persists for 18-20 hours.

For kidney disease

Kidney pathologies lead to insufficient blood filtration, accumulation of metabolic products and toxins. Diuretics help to compensate for the insufficient filtering ability of the nephron. Indications for the appointment of diuretics are renal failure, chronic infectious lesions in the acute stage, urolithiasis. As a rule, in these cases apply:

1. Mannitol. Osmodiuretic, increases plasma filtration and osmotic pressure. The drug has a moderate natriuretic effect. Diuretic action begins in the first minutes after parenteral administration (about 5-10 ml of a 15% solution) and lasts 36-40 hours. Apply a medication for forced diuresis with glaucoma or cerebral edema.
2. Oxodollin. The main active ingredient is chlortolidone. Oxodollin inhibits sodium reabsorption. The action begins 2-4 hours after ingestion, lasts 26-30 hours. The dosage for kidney disease is 0.025 g once a day.

With edema

Puffiness often occurs without the presence of a disease and is the result of excessive consumption of salt, sweets, alcoholic beverages. To eliminate this unpleasant symptom, diuretics are indicated:

1. Amiloride. Medication from the group of potassium-sparing diuretics. Amiloride begins to act 2 hours after ingestion, the effect persists for 24 hours. The approximate single dosage is 30-40 mg.
2. Diacarb. The active substance is acetazolamide. Diacarb has a weak but long-lasting effect. After oral administration (250-500 mg), the effect occurs after 60-90 minutes and lasts up to 2-3 days.

For weight loss

Diuretics in a few days will help reduce body weight by 1-3 kg, but at the same time do not affect the fat content in the body. When you stop using diuretic drugs, the weight will return, so such drugs are not recommended for weight loss for longer than 2-3 days. Long-term use of diuretics to reduce body weight can lead to impaired renal function up to renal failure. For short-term weight loss, the following drugs are suitable:

1. Lasix. The active ingredient of the drug is furosemide. Lasix has a rapid diuretic effect, inhibits the reabsorption of sodium, chlorine and potassium. The recommended single dosage is 40-50 mg. The action of Lasix begins 30-40 minutes after ingestion and lasts 6-8 hours.
2. Uregit. A fast-acting diuretic containing ethacrynic acid, which slows down sodium transport. the effect occurs 30 minutes after ingestion, lasts for 10-12 hours. A single dosage is 25-50 mg.

drug interaction

Diuretic drugs are often prescribed as part of complex drug therapy simultaneously with other medicines, so you should study the features of the interaction of diuretics with other drugs:

1. Diuretics that remove potassium should not be taken with digitalis derivatives, because this increases the risk of developing an arrhythmia.
2. Poorly combined potassium-sparing diuretics with potassium preparations: this causes an excess of this ion, which provokes paresis, muscle weakness and respiratory failure.
3. Drugs that reduce the concentration of glucose in the blood enhance the hyperglycemic effect of diuretics.
4. Antibacterial agents of the aminoglycoside and cephalosporin series in combination with loop diuretics can lead to the development of acute renal failure.
5. Non-steroidal anti-inflammatory drugs, proton pump inhibitors reduce the diuretic effect of diuretics.
6. Benzothiadiazine derivatives in combination with diuretics can disrupt myocardial microcirculation and contribute to the development of blood clots.

Side effects of diuretics

Diuretics, removing electrolytes necessary for the body, cause some side effects.. As a rule, these are the consequences of the violation of ionic equilibrium. These include:

• hypokalemia (decrease in potassium levels);
• hypomagnesemia (decrease in magnesium concentration);
• leaching of calcium from the body;
• arrhythmia;
• metabolic alkalosis;
• dehydration;
• irritability;
• darkening in the eyes;
• sleep disorders;
• loss of working capacity;
• tachycardia;
• dyspnea;
• hyponatremia (decrease in the amount of sodium).

Loop diuretics are the most dangerous because they have a powerful and fast effect. Even a small deviation from the recommended dosage of these drugs can cause a number of unwanted side effects. Less dangerous diuretics are drugs of the thiazide group. They have a long, but mild effect, without dramatically changing the composition of the blood, so they are suitable for long-term use.

Contraindications

Due to the fact that diuretics have a general effect on the body, i. cause changes in the functioning of two or more organ systems, there are some restrictions for their use. The main contraindications for the use of diuretic drugs:

• liver failure;
• pregnancy;
• epileptic seizures;
• lactation period;
• diabetes;
• hypovolemic syndrome;
• severe anemia;
• atrioventricular block;
• some severe congenital heart defects.

How to choose diuretics

Safe for self-use are diuretics of plant, natural origin, infusions, decoctions of herbs. If you need to use synthetic diuretics, you should seek the advice of a doctor who will determine which drug should be taken in your case, the duration of drug therapy and dosage. When choosing a diuretic for a patient, the doctor takes into account the following factors:

• the presence of chronic diseases of the cardiovascular system;
• the presence of endocrine diseases;
• weight and age of the patient;
• the need for simultaneous use with other drugs;
• clinical picture of the current disease;
• allergic history.

Video

home » Soft roof » Osmotic diuretics. Diuretic drugs: list and characteristics