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diuretic

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Diuretics, fluid retention heart failure (Heart failure) is an important component of patient treatment strategy. use separately Furosemide Or single use captopril treatment contrast test It was found that fluid retention often occurred in patients with heart failure who were treated with captopril, rather than those who were treated with diuretics. Multicenter test All the patients included were patients with heart failure whose symptoms and fluid retention were completely controlled, who could not maintain clinical stability for a long time with a single diuretic Angiotensin converting enzyme inhibitor （ ACEI ）Combined application will reduce the chance of clinical decompensation. Therefore, diuretics are indispensable for the treatment of heart failure.

Drug name: diuretic
Foreign name: Diuretics

Careful use by athletes: yes
Drug type: chemical
Origination: 1948

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classification

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Diuretics can be divided into several types. Different diuretics have different diuretic principles or different parts of action, and their side effects are largely the same. Diuretics can lead to decreased blood pressure and dehydration. Most diuretics cause Hypokalemia , except potassium sparing diuretics. Patients with hypokalemia are encouraged to eat foods rich in potassium. Attention should be paid to blood potassium when using diuretics, because hypokalemia can easily lead to digitalis poisoning. Diuretics are generally recommended to be taken in the morning, not at night before sleep, so as not to affect sleep. Observe the urine volume after using diuretics.

Thiazides: such as Chlorothiazide （chlorothiazide）， Chlorthiazone （chlorthalidone）。 It mainly acts on the kidney Distal convoluted tubule , Sodium inhibited Reabsorption So the sodium is discharged and the water is discharged. Side effect: kidney damage, so there is kidney disease Should not be used. Low potassium Hyponatremia , hypotension, blood suppression.

Medullary loop Diuretics, also called diuretics Heinz Loop diuretics: the main drug is furosemide (Lasix), which inhibits sodium reabsorption in the medullary loop. It causes low sodium and potassium, gastrointestinal discomfort, hypotension, blood suppression, and other important side effects: Ototoxicity 。

protect potassium Diuretics (Potassium sparing diuretics): most diuretics excrete potassium, and only a few diuretics retain potassium. The most common one in the RN exam is Spironolactone Potassium retaining diuretic, spironolactone（ Spironolactone The main side effects of these drugs are Hyperkalemia , blood suppression, low potassium diet.

Osmotic diuretics: Yes osmotic pressure Of crystal Get to the kidney and take the water out of the body. The main ones are mannitol （Mannito），Urea（ urea ）

Product Introduction

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Diuretics began to reduce blood pressure in 1948, but due to the toxicity and necessity of mercury diuretics intramuscular injection , cannot be popularized. Chlorothiazide came out in 1957. For more than 30 years Hydrochlorothiazide (Dihydrochlorothiazide) based thiazide diuretics have always been anti Hypertension drugs Of Main force One, whether used alone or with other anti hypertension The combination of drugs has clear curative effect. The results of large-scale international clinical trials over the past decades have further confirmed its position in the treatment of hypertension. Europe and America Several hypertension management principle committees recommend none complication The first choice of diuretics was diuretics. Until the recent JNC-VI report (1997) in the United States, it was still advocated that none complication Patients with hypertension, with diuretics and Beta blocker It is a first-line drug. In recent years, new diuretics Indapamide （ Shoubi Mountain The launch of indapmid) has improved the position of diuretics in the treatment of hypertension. It is characterized by that the commonly used dosage only shows slight diuretic effect, mainly shown as Vasodilation Action (the drug has calcium Antagonism ）, depressurization Efficiency It is about 80%, and does not have the side effects of metabolic abnormalities caused by traditional diuretics. It has been widely used in clinical practice.

effect

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According to the results of international large-scale clinical trials, it is proved that the effect of diuretics on reducing blood pressure is positive. In the combined medication, when other antihypertensive monotherapy is ineffective, diuretics are added, and the effect is significant. Diuretics, especially for the elderly and obese Hypertensive patients The effect is more obvious.

usage

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1. Single drug treatment: according to the generally recommended dosage, all kinds of anti Hypertension drugs The range of blood pressure reduction is generally similar. The typical situation is placebo Control ratio, average systolic pressure 160/95 mmHg Usually, single drug treatment reduces systolic blood pressure by 7~13mmHg and diastolic pressure 4～8mmHg。

two Combined medication Treatment: there are 6 kinds of anti Hypertension drugs Any combination of two or more drugs can reduce blood pressure more than any single drug. HOT test proved that the combination of drugs is very effective. The hypotensive effect of combination drugs is about twice as large as that of single drug treatment, that is, if the blood pressure of patients with 160/95mmHg is reduced by 8-15%, that is, the systolic pressure is reduced by 12-22mmHg and the diastolic pressure is reduced by 8-12mmHg

3. Effective drugs combined with diuretics

Diuretic+ Beta blocker , Diuretics+ ACEI Or AT Ⅱ RA

matters needing attention

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1. Treatment of thiazide diuretics hypertension , especially suitable for light Moderate hypertension Patient, elderly simple systolic hypertension, obesity and hypertension heart failure Patients.

2. Decide whether to use it according to whether there are accompanying diseases Hydrochlorothiazide , Yes Sugar tolerance Lower or diabetes Generally, hydrochlorothiazide is not suitable; with hyperuricemia Contingent gout Patients should not use hydrochlorothiazide, or their condition will worsen; Renal insufficiency ， Blood creatinine More than 290 μ mol/L It is also not suitable for application.

3. On Hypertension emergency Short acting diuretics such as furosemide should be used. Hypertension is often treated for life. Long acting diuretics such as Indapamide (indapmid), less side effects. Hydrochlorothiazide and Calcium antagonist or ACEI It can be used in small amount, 6.25~12.5mg/day. Spironolactone （ Spironolactone , spironolactone) commonly used in hypertension heart failure Of patients, Aminopteridine (triamterene) has weak diuretic effect and is rarely used alone.

4. Its side effects are dose related, so the dose should be small.

5. Patients should not limit sodium excessively or take high sodium intake. Generally, they should limit sodium moderately, 5-8g per day.

6. Take an appropriate amount of potassium supplement, 1-3 grams per day, or use potassium sparing diuretics in combination. Encourage people to eat more potassium rich foods and fruits, such as celery, Banana , orange juice, etc. To sum up, in hypertension After 40 years of long-term treatment, diuretics are still Be treated as First-line medication 。 However, in the treatment, appropriate patients should be selected and possible side effects should be noted.

side effect

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1. "Cardiotoxicity" of diuretics. In 1987, Kaplan, a famous American heart expert, believed that hydrochlorothiazide could not be reduced myocardial infarction incidence rate , possibly due to "cardiotoxicity" and Lipid metabolism disorder Caused by. Multiple risk factor intervention trials in the United States found that hypertension patients with Abnormal ECG Sudden death increased after diuretic treatment. Framingham's epidemiology It is also reported that diuretics may increase the risk of sudden death in the treatment of hypertension. However, some scholars think that no matter whether there is data or not Hypokalemia No increase in thiazide diuretics Ventricular arrhythmia The incidence of.

two Hypokalemia 。 Various diuretics can reduce the blood potassium by about 0.5mmol/L, some patients can maintain the blood potassium in the normal range, but 10-15% of patients can reduce the blood potassium to less than 3.5mmol/L, some patients even if the blood potassium is normal, but the whole body is Potassium deficiency Status, also available in Stress response When potassium enters the cell, hypokalemia occurs, which can increase the stress response Myocardial ischemia Malignancy caused by Ventricular arrhythmia 。 Among various diuretics, thiazide diuretics and furosemide cause obvious hypokalemia. Long acting thiazide diuretics (such as Chlorthiazone ）It is more obvious than the medium effect hydrochlorothiazide. The hypokalemia caused by hydrochlorothiazide is related to the dose. The higher the dose, the higher the incidence of hypokalemia. If moderate sodium restriction (60~80mEg/day) causes the least loss of potassium, high sodium or excessive sodium restriction causes hypokalemia. Therefore, potassium sparing diuretics or appropriate potassium supplement can be added during application.

3、 Carbohydrate metabolism 。 Some studies prove that Hydrochlorothiazide Can make Fasting blood glucose Increase, Sugar tolerance Decrease and increase the incidence of hypertension insulin resistance 。

4、 Lipid metabolism 。 Most reports that long-term use of hydrochlorothiazide can cause fat Metabolic disorder , mainly the impact lipase The activity of triglyceride Catabolism Reduce the rise of triglyceride; It can also cause mild cholesterol Increase.

Adverse reactions

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Reduce circulation through its diuretic and natriuretic effects Blood volume , and by reducing Vascular wall in Sodium ion The content of Vascular tension 。 Diuretics are widely used heart failure And the treatment of hypertension, and plays a pivotal role in the treatment of these diseases. As for this kind of Adverse drug reactions The popularization of knowledge, through reasonable combination of drugs, has greatly reduced Adverse reactions Occurrence of. Common adverse reactions include:

Electrolyte disorder

They are low in potassium, sodium, chlorine, calcium and magnesium.

It is a common side effect associated with the diuretic effect of diuretics. It is particularly prone to occur in the case of large dose, long course of treatment, and the use of loop diuretics, and low potassium and Hyponatremia Most common. Hypokalemia Can cause fatigue Arrhythmia 、 Intestinal peristalsis Disorders (even Enteroparalysis ）Excessive digitalis; Hyponatremia causes burnout Lethargy , irritability or even coma; Hypocalcemia Cause arrhythmia Muscle spasm , convulsions, etc; Hypomagnesemia Causes arrhythmia. In clinical practice, the following methods can be used to avoid or reduce the Electrolyte disorder 。

terms of settlement

1. Supplement electrolyte In order to avoid the occurrence of electrolyte disorder, the most commonly used method in clinical practice is to supplement properly. Oral or intravenous potassium supplementation is the most commonly used method. In order to avoid gastric irritation caused by oral potassium supplements Slow-release potassium Oral. according to diuresis The dosage of potassium supplement depends on the degree of potassium supplementation. During the supplement process, the electrolyte should be rechecked. Other electrolytes are not routinely supplemented when diuretics are used, but must be supplemented in the following cases: low sodium, low magnesium or hypocalcemia is found during biochemical determination; When digitalis is excessive, magnesium is usually supplemented routinely; When a muscle twitch occurs in a part of the body, hypocalcemia is considered.

It was previously believed that small doses of thiazide diuretics such as Hydrochlorothiazide 12.5 mg, or Indapamide 2.5mg will not cause Hypokalemia , but Practical proof It is advisable to supplement a small amount of potassium at the same time in old age and poor eating.

2. With potassium sparing diuretics or Angiotensin converting enzyme inhibitor (ACEI) combination: when a small dose of thiazide diuretic (12.5~25mg) is combined with potassium retaining diuretics or ACEI, it is generally not necessary to add additional potassium, but because individual difference It is relatively large, so the blood potassium should be rechecked at the early stage of medication. On the contrary, when large doses of diuretics, especially loop diuretics, are used together with the above drugs, the dosage of potassium supplement should be reduced according to the situation, and attention should be paid to rechecking the electrolyte.

Decreased blood pressure

Diuretics induced changes in blood pressure are common in the elderly Insufficient blood volume When vasodilators are used at the same time or large doses of loop diuretics are used intravenously. stay heart failure Application of diuretics in patients Add down When using ACEI, to avoid the first dose hypotension The occurrence of acute pancreatitis needs to start from a small dose, and if necessary, ACEI should be added 1 to 2 days after discontinuation of diuretics.

Elevated blood uric acid

It is an adverse reaction of long-term use of diuretics in large doses. It is common in patients with heart failure. It should be measured regularly Blood uric acid Level, if necessary, add uric acid lowering drugs such as Allopurinol 。

Impaired glucose tolerance

It is also an adverse reaction of long-term use of large doses of diuretics. The dosage of medication should be reduced as far as possible to avoid it. For patients whose dosage cannot be reduced, attention should be paid to appropriately reduce weight and increase the amount of activity.

Metabolic disorder

It is an adverse reaction of long-term use of diuretics in large doses. As triglyceride And cholesterol increase, if necessary, use lipid regulating drugs.

Azotemia

It is commonly used in the case of insufficient circulating blood volume caused by drugs, such as large dose of diuretics, or when combined with other vasodilators. In patients with heart failure, diuretic related Azotemia It is common. The treatment methods include properly reducing the dosage of diuretics or ACEI, and appropriately expanding the volume when necessary.

Diuretics play an important role in modern hypertension treatment. However, in most cases, small doses of thiazides are recommended, mainly Hydrochlorothiazide 6.25 ～ 25mg/d, which is less likely to cause Electrolyte disorder , rarely cause obvious metabolic abnormalities. Loop diuretic is only used for hypertensive patients Renal insufficiency Patients.

stay heart failure Diuretics are one of the most effective drugs to relieve patients' symptoms. With the full play of diuretics, Urine output We should pay attention to supplement electrolytes and take intravenous medication Acute heart failure Special attention shall be paid to. about chronic heart failure It is often used together with ACEI. For patients with severe heart failure, a small dose of spironolactone is also recommended. Therefore, it is necessary to recheck blood potassium and supplement potassium appropriately according to the situation.

Bad causes

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（1） Renal blood flow Decrease. The effect of diuretics depends on adequate renal blood flow. Only by maintaining important renal blood flow can diuretics give full play to its diuretic effect;

（2） Electrolyte disorder 。 In the process of diuresis, especially when a large number of drugs are used continuously, electrolyte disorder often occurs, leading to the decline of diuretic effect;

（3） secondary aldosterone Increase. cirrhosis After a large amount of diuresis, the decrease of effective circulation volume may cause the secondary increase of anabolism Alkalosis ；

（4） Colloid osmotic pressure Impact. Edema or ascites Is often accompanied by low Plasma protein Plasma protein is the main maintenance Blood volume Factors. Plasma colloid osmotic pressure When lowering, Interstitial fluid It is not easy to enter the blood vessels, and if not corrected, the effect of diuretics can be reduced;

(5) A weak constitution. Physical weakness, often secondary adrenal cortex The function is delayed, so the response to diuretics is poor prednisone or dexamethasone After 3-5 days, good reaction can be obtained by using diuretic;

(6) Others. Rest or avoiding salt is also an important link to ensure the effectiveness of diuretics, Etiological treatment of course Not to be ignored In addition, attention should also be paid to whether there is low blood sodium and other conditions. The diuretic effect can be obvious only after correcting the causes of non directional low blood sodium.

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