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Use of Diuretics in Cardiovascular Disease: (2) Hypertension S U Shah, S Anjum, W a Littler

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Use of Diuretics in Cardiovascular Disease: (2) Hypertension S U Shah, S Anjum, W a Littler 271 REVIEW Postgrad Med J: first published as 10.1136/pgmj.2003.010751 on 11 May 2004. Downloaded from Use of diuretics in cardiovascular disease: (2) hypertension S U Shah, S Anjum, W A Littler ............................................................................................................................... Postgrad Med J 2004;80:271–276. doi: 10.1136/pgmj.2003.010843 Hypertension is a common condition associated with (frusemide, bumetanide, and ethacrynic acid) decrease sodium resorption in the thick ascend- increased mortality and multiple morbidities. Evidence ing loop of Henle by interfering with the Na–K+– based management of hypertension is known to improve 2Cl– cotransport system located at the apical both the short term and the long term outcomes in patients membrane of the renal tubule. These diuretics act at a site where a large quantity of sodium is with this condition. There are several general measures normally reabsorbed. Therefore, the amount of and pharmacological agents that are known to treat urinary sodium excretion and accompanying hypertension adequately. Diuretics, in particular low dose fluid loss can be enhanced considerably with these agents by increasing the dose. Loop thiazide and thiazide-like diuretics, are widely used in the diuretics are effective even in patients with treatment of hypertension. They have excellent outcome severely impaired renal function. Thiazides, data and high safety and low side effects profiles. In this metolazone, and indapamide inhibit sodium resorption in the early portion of the distal article, the physiology, pharmacological actions, side convoluted tubule. These diuretics inhibit the effects, and outcome data of the use of diuretics in apical Na+–Cl– cotransport system. Only a small hypertension are reviewed. In addition, the effective use of fraction of the filtered sodium is normally reabsorbed at this site, which explains the diuretics in the management of hypertension is discussed. limited natriuretic activity of this class of ........................................................................... diuretics. The dose-response curves for these diuretics are rather flat. Furthermore, the iuretics have been used effectively to treat natriuretic effect of thiazides and to some extent millions of hypertensive patients during indapamide is lost when the glomerular filtration Dthe past four decades. They reduce both rate (GFR) is reduced below about 40 ml/min, systolic and diastolic blood pressures in the great whereas metolazone is still active down to a GFR majority of hypertensive patients. They are as of about 20 ml/min. effective as most other antihypertensive drugs.12 In the distal convoluted tubule and in the Diuretics administered alone or in combination cortical collecting duct, sodium is transported at with other agents form the basis of therapy for the apical level of the tubular cell through a the majority of hypertensive patients.3 A thiazide sodium channel. Sodium is then exchanged for http://pmj.bmj.com/ is the usual choice, generally in combination potassium at the basal membrane as a result of with other antihypertensive agents.4 Loop diure- the activity of Na+–K+ ATPase. The activity of this tics are usually reserved for patients with renal enzyme is enhanced by aldosterone, the miner- insufficiency, resistant hypertension, or heart alocorticoid hormone secreted by the adrenal failure. Diuretics are prescribed for patients with zona glomerulosa. Loop diuretics, thiazides, and hypertension because of, firstly, their efficacy, metolazone, as well as triamterene, amiloride, low cost, and low side effects profile; secondly, and spironolactone, act in the late portion of the their synergistic effect when combined with distal convoluted tubule and the cortical collect- on October 2, 2021 by guest. Protected copyright. other antihypertensive agents; thirdly, the fact ing duct. Triamterene and amiloride have weak that they counteract salt and fluid retention natriuretic action. Spironolactone is a competi- caused by other antihypertensive agents; and, tive antagonist of aldosterone and, consequently, fourthly, their usefulness in patients with heart inhibits pump activity. Amiloride and triamter- failure. ene block the apical sodium transport. The elimination of potassium is reduced by diuretics CLASSIFICATION AND MECHANISM OF acting in the most distal portions of the nephron ANTIHYPERTENSIVE ACTION because of decreased sodium-potassium Diuretics useful in the treatment of hypertension exchange. In contrast, loop diuretics and diure- See end of article for may be divided into four major groups according tics acting in the early distal convoluted tubule authors’ affiliations ....................... to their primary site of action within the renal increase kaliuresis and tend to cause hypokalae- tubule, starting in the proximal portion and mia. This is mainly because these agents enhance Correspondence to: moving to the collecting duct.5 They include the delivery of sodium downstream and subse- Dr Saeed Ullah Shah, 17 South Street, Harborne, agents acting on the proximal tubule, such as quently accentuate the sodium-potassium Birmingham B17 0DB, UK; carbonic anhydrase inhibitors, which have lim- exchange. As a result, more sodium is available saeedshah@miranshah. ited antihypertensive efficacy; loop diuretics; for resorption in the late distal convoluted tubule freeserve.co.uk thiazides and related sulphonamide compounds; and the cortical collecting duct. and potassium sparing agents (table 1). Submitted 7 June 2003 Accepted A common feature of all diuretics is their Abbreviations: ACE, angiotensin converting enzyme; 5 November 2003 natriuretic action, which leads to a decrease in ARB, angiotensin receptor blocker; CI, confidence ....................... total body sodium. The most potent diuretics interval; GFR, glomerular filtration rate www.postgradmedj.com 272 Shah,Anjum,Littler Table 1 Diuretics used in the treatment of hypertension Postgrad Med J: first published as 10.1136/pgmj.2003.010751 on 11 May 2004. Downloaded from Optimal dose Duration of Class Example(s) Mechanism(s) (mg) action (h) Advantages Disadvantages Comments Thiazides Hydro- Natriuresis 12.5–25.0 mg 6–12 Potentiates other Hypokalaemia Especially effective in chlorothiazide once daily antihypertensives black patients, the obese, and the elderly Chlorothiazide Vasodilatation 125–250 mg 6–12 Hyperuricaemia once daily Bendrofluazide 1.25–2.5 mg 6–12 Low cost Hypercholesterolaemia once daily Trichlorothiazide 1–2 mg 6–12 Proven end organ Hyperglycaemia Mediated via once daily efficacy low K+ Thiazide Chlorthalidone Natriuresis 12.5–25.0 mg 6–12 Lasts 24–48 h Hypokalaemia Especially effective in related once daily black patients, the obese, and the elderly Indapamide Vasodilatation 1.5–2.5 mg 16–36 Works even if GFR is Hyperuricaemia once daily below 50 ml/min Metolazone 0.5–2.5 mg 18–25 Works even if GFR is Hypercholesterolaemia once daily below 50 ml/min K+ Spironolactone Natriuresis 25–100 mg 3–5 days Spares K+ Gynaecomastia Higher doses in primary sparing once daily hyperaldosteronism Triamterene 25–50 mg 8–12 No effect on glucose, Little hypotensive Use with caution in once daily or uric acid, or lipid effect on its own patients with renal twice daily dysfunction Amiloride 5 mg once 6–24 daily Loop Frusemide Natriuresis 10–40 mg 4–5 More potent diuresis Hypokalaemia Less effective twice daily antihypertensive effects despite greater diuresis Bumetanide 0.5 mg 4–5 Hyperuricaemia twice daily Ethacrynic 25 mg 4–8 Hypercholesterolaemia acid once daily GFR, glomerular filtration rate. The exact mechanism of antihypertensive action of diuretics is not known.6 All diuretics initially lower the blood Table 2 Side effects related to the use of pressure by increasing urinary sodium excretion and redu- diuretics cing plasma volume, extracellular fluid volume, and cardiac http://pmj.bmj.com/ General side effects output. Within six to eight weeks, the plasma volume, Electrolyte disturbances extracellular fluid volume, and cardiac output return towards Hyponatraemia normal. Beyond this point, the lower blood pressure is related Hypokalaemia to a decline in peripheral resistance, thereby improving the Hypomagnesaemia 7 Hypocalciuria underlying haemodynamic defect of hypertension. The Hyperuricaemia vasodilatory effect of diuretics is probably related to the loss Impotence of sodium and water from the vessel wall.8 In addition, some Metabolic alkalosis on October 2, 2021 by guest. Protected copyright. of the vasodilatory action is mediated through the release of Perturbation of carbohydrate metabolism prostacyclin and endothelial derived relaxing factor.9 The Hyperglycaemia Insulin resistance mechanism responsible for the lowered peripheral resistance Decreased insulin secretion may also involve activation of the potassium channel.10 Non-ketotic hyperosmolar state Lipid abnormalities Increased low density lipoprotein SIDE EFFECTS Increased very low density lipoprotein The side effects of high dose diuretic therapy are usually not Increased total cholesterol overly bothersome, but the hypokalaemia, hypercholestero- Increased triglycerides laemia, hyperinsulinaemia, and worsening of glucose toler- Specific side effects Frusemide: ototoxicity ance that often accompany prolonged high dose diuretic Spironolactone: gynaecomastia and galactorrhoea therapy raise concerns about the long term benignity of this Acetazolamide: metabolic acidosis treatment (table 2). However, lower doses are usually
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