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1. Diuretics: Definition, Classification According to the Localization of Action in Nephron, Strength and Speed of Onset and Duration of Effect

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1. Diuretics: Definition, Classification According to the Localization of Action in Nephron, Strength and Speed of Onset and Duration of Effect DRUGS AFFECTING THE FUNCTIONS OF EFFECTOR ORGANS AND SYSTEMS LESSON 13. DIURETIC DRUGS Key questions: 1. Diuretics: definition, classification according to the localization of action in nephron, strength and speed of onset and duration of effect. 1.1. Carbonic anhydrase inhibitors (acting on the proximal renal tubules) – acetazolamide. 1.2. Loop diuretics (acting on the ascending part of loop of Henle): furosemide, bumetanide, torasemide. 1.3. Thiazide (hydrochlorothiazide, bendroflumethiazide) and thiazide-like (chlorthalidone, indapamide, xipamid, metolazone) diuretics acting on the initial part of the distal renal tubules. 1.4. Potassium-sparing diuretics (acting on the distal renal tubules and collector renal tubules): sodium channels inhibitors (triamterene, amiloride), aldosterone antagonists (spironolactone, eplerenone). 1.5. Osmotic diuretics (acting on the proximal renal tubules, the descending part of the loop of Henle and collector renal tubules) – mannitol. 1.6. Side effects of diuretics, including water-electrolyte and metabolic disorders. 1.7. Use of diuretics: arterial hypertension, chronic heart failue, edemas, oliguric renal failure, acute intoxications, hyperaldosteronism, glaucoma, etc 1.8. Criteria for diuretics selection: speed of onset and time to maximum diuretic effect; the duration and intensity of the effect; the level of electrolytes and blood coagulation potential; glomerular filtration rate; methods and mechanisms of excretion. 1.9. Combined use of diuretics. Rational combination of different diuretics and diuretics with drugs of other pharmacological groups. 1.10. Absolute contraindications to the use of diuretics 2. Drugs that increase the glomerular filtration: xanthines, cardiac glycosides, dopamine; mechanism of action, clinical use. 3. Uricosuric drugs: indacrinone, ticrynafen (rarely use). 4. Antagonists of the antidiuretic hormone (aquaretics), acting on the collector renal tubules: demeclocycline, conivaptan, tolvaptan 5. Agonists of the antidiuretic hormone – desmopressin. As a result, you should be able to: . Name the 5 major types of diuretics and specify the location of their action. Specify the main indications for use and side effects of acetazolamide, thiazides, loop and potassium-sparing diuretics. To characterize the 2 drugs that reduce potassium loss with sodium diuresis. Specify how you can reduce calcium excretion in urolithiasis. Approach to the treatment of acute severe hypercalcemia in patients with advanced carcinoma. Specify what should be appointed with nephrogenic diabetes to reduce the volume of urine. Specify what should be assigned to increase the excretion of water at a syndrome of excessive secretion of ADH. Write out the following drugs: hydrochlorothiazide (tablets), furosemide (solution), chlorthalidone (tablets), spironolactone (tablets). PRESCRIPTION PRESCRIPTION Date "___" ________________ 20___. Date "___" ________________ 20___. Full name of the ____________________________ Full name of the ____________________________ patient __________________ patient __________________ Age ____________________________ Age ____________________________ __________________ __________________ Full name of the ____________________________ Full name of the ____________________________ doctor __________________ doctor __________________ Rp.: Rp.: Rp.: Rp.: Signature of the doctor Signature of the doctor LESSON 14. ANTIHYPERTENSIVE DRUGS Key questions: 1. The main pharmacological approaches to the management of arterial blood pressure. 2. Classification of antihypertensive drugs: 2.1. Diuretics: thiazide and thiazide-like (hydrochlorothiazide, indapamide, chlorthalidone, metolazone); loop (furosemide, bumetanide, torasemide); potassium-sparing (amiloride, triamterene, spironolactone). 2.2. Inhibitors of the renin-angiotensin-aldosterone system (RAAS). 2.2.1. Inhibitors of angiotensin-converting enzyme (ACE): short-term action (3 times a day) – captopril; average-term action (1-2 times a day) – enalapril, benazepril, quinapril, moexipril, ramipril; long-term action (once per day): lisinopril, fosinopril, perindopril, trandolapril. 2.2.2. Angiotensin receptors AT1 antagonists (ARB, angiotensin II antagonists): losartan, valsartan, candesartan, azilsartan, irbesartan, olmesartan, telmisartan. 2.2.3. Combined drugs of RAAS inhibitors with diuretics and / or CCB, proof of the benefits and use of such combinations. 2.2.4. Renin inhibitor – aliskiren. 2.3. Sympathoplegic drugs. 2.3.1. Central 2-adrenergic and I1-imidazoline receptors agonists: clonidine, guanfacine, methyldopa. 2.3.2. -adrenergic antagonists: nonselective – propranolol, nadolol, timolol; cardioselective – atenolol, bisoprolol, betaxolol, metoprolol; with additional NO- depended vasodilatation – nebivolol; with ISA – acebutolol, carteolol, penbutolol, pindolol. 2.3.3. Mixed-action adrenergic antagonists: carvedilol, labetalol, proxodolol. 2.3.4. -adrenergic antagonists: doxazosin, prazosin, terazosin, nicergoline. 2.3.5. Sympatholytics: reserpine, guanethidine, guanadrel (rarely use). 2.3.6. Ganglionic blockers: trimethaphan, hexamethonium (rarely use). 2.4. Calcium L-type channel blockers (CCBs): vasodilating (CCB with the predominant effect on the blood vessels) – dihydropyridine derivatives: nifedipine and its retard forms, amlodipine, felodipine, nicardipine, nisoldipine, nitrendipine, lacidipine, lecarnidipine (exept nimodipine); bradycardic (CCB with the predominant effect on the heart): phenylalkilamin derivatives – verapamil, gallopamil; benzothiazepine derivatives – diltiazem. 2.5. Vasodilators: arteriolar – minoxidil, hydralazine, diazoxide; arteriolar and venous – sodium nitroprusside, nitroglycerine, magnesium sulfate, bendazol (dibazol). 3. Molecular and hemodynamic mechanisms of action of antihypertensive drugs, side effects, dosage regimen, contraindications and precautions for their use. 4. The choice of drugs for the individual therapy of arterial hypertension: 1st line drugs (standard therapy): ACE inhibitors, blockers, thiazide diuretics, CCBs, beta-blockers (mono- or combination therapy); adjuvants: alpha blockers, renin inhibitors, vasodilators, sympatholytic (in addition to group 1); hypertension + ChHF: RAAS inhibitors, aldosterone antagonists, diuretics, beta- blockers; hypertension in pregnant women: methyldopa (traditional first-choice drug), labetalol (fewer side effects in comparison methyldopa), clonidine, beta blockers (except atenolol), CCLBs (except nifedipine); RAAS inhibitors are contraindicated; hypertension + postinfarction period: beta-blockers without the ISA, RAAS inhibitors, thiazides; hypertension + ischemic heart disease: beta-blockers, CCBs (retard forms), RAAS inhibitors, diuretics; hypertension in the elderly: CCB (!) + other 1st line drugs; hypertension in chronic kidney disease: RAAS inhibitors (with caution), thiazides; metabolic syndrome (obesity + hypertension + insulin resistance): thiazides (!), RAAS inhibitors, CCBs. hypertension + erectile dysfunction: avoid alpha 2 and I1 agonists (central action); hypertension + diabetes: preferred RAAS inhibitors (ACE inhibitors, ARB), chlorthalidone, in old age - CCBs. hypertension in children and adolescents (mostly secondary): inhibitors of the RAAS, CCB, beta-blockers, thiazides. 5. Drugs for the emergency control of arterial blood pressure. 5.1. Relief of hypertensive crises: captopril, enalaprilat, labetalol, clonidine, nicardipine, hydralazine, nitroglycerin, sodium nitroprusside, esmolol, fenoldopam, magnesium sulfate, bendazol (applied depending on the clinical condition of the patient). Dangers of acute decline of blood pressure (development of renal, cerebral and coronary ischemia). 5.2. Prevention of rupture of an aortic aneurism: -adrenergic antagonists, vasodilators. 5.3. Control blood pressure in severe heart failure: ACE inhibitors, myotropic vasodilators, - adrenergic antagonists, CCBs. 5.4. Controlled hypotension – sodium nitroprusside, trimethaphan. 5.5. Control blood pressure in pheochromocytoma - doxazosin, prazosin, terazosin. 5.6. Agents used in pulmonary arterial hypertension – sildenafill, tadalafil. As a result, you should be able to: . Name 4 main groups of antihypertensive agents, give examples of drugs. Identify main target of action of sympatoplegic agents, give examples of drugs acting on these targets. Identify differences in action between three types of RAAS inhibitors. Identify compensatory reactions of the body (if they occurred) resulting from the action of each of the main 4 groups of antihypertensive drugs. Identify main diuretics used in hypertension and prove their effectiveness. Identify the main antihypertensive vasodilators and describe their effects. Identify 4 mechanisms of action of vasodilators. Identify preferred combinations of antihypertensive drugs. Identify preferred drugs for treatment of systolic hypertension. Identify preferred drugs for treatment hypertension in pregnant women. Identify the main side effects of antihypertensive drugs prototypes. Write out the following drugs: indapamide (coated tablets), enalapril (tablets), lisinopril (tablets), losartan (tablets), candesartan (tablets), amlodipine (tablets), diltiazem (coated tablets), nebivolol (tablets), carvedilol (tablets), doxazosin (tablets), moxonidine (tablets), clonidine (tablets). PRESCRIPTION PRESCRIPTION Date "___" ________________ 20___. Date "___" ________________ 20___. Full name of the ____________________________ Full name of the ____________________________ patient __________________
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