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The American Journal of Medicine Dec 2006Intravenous (IV) loop diuretics play an important role in the treatment of decompensated heart failure (DHF). They inhibit the Na(+)-K(+)-2Cl(-) reabsorptive pump in the... (Review)
Review
Intravenous (IV) loop diuretics play an important role in the treatment of decompensated heart failure (DHF). They inhibit the Na(+)-K(+)-2Cl(-) reabsorptive pump in the thick ascending limb of the loop of Henle, and the resultant natriuresis and diuresis decreases volume load, improves hemodynamics, and reduces DHF symptoms. However, loop diuretics have a short half-life and their efficacy may be limited by postdiuretic sodium rebound during the period between doses in which the tubular diuretic concentration is subtherapeutic. Moreover, they can produce electrolyte abnormalities, neurohormonal activation, intravascular volume depletion, and renal dysfunction. Several studies have reported an association between diuretic therapy and increased morbidity and mortality. In addition, many patients, especially those with more advanced forms of heart failure (HF), are resistant to standard doses of loop diuretics. These high-risk, resistant patients may benefit from pharmacologic and/or nonpharmacologic interventions to improve hemodynamic performance, treatment of renovascular disease, discontinuation of aspirin and other sodium-retaining drugs, manipulation of the route of delivery or combination of diuretic classes, or hemofiltration. Despite >50 years of use, many questions regarding the use of intravenous diuretic agents in patients with DHF are still unanswered, and there remains a compelling need for well-designed randomized, controlled clinical trials to establish appropriate treatment regimens that maximize therapeutic benefit while minimizing morbidity and mortality.
Topics: Diuretics; Drug Resistance; Heart Failure; Humans; Infusions, Intravenous; Randomized Controlled Trials as Topic; Treatment Failure; Water-Electrolyte Balance
PubMed: 17113397
DOI: 10.1016/j.amjmed.2006.09.014 -
Journal of Cardiac Failure Jan 2022The concept of multinephron segment diuretic therapy (MSDT) has been recommended in severe diuretic resistance with only expert opinion and case-level evidence. The...
BACKGROUND
The concept of multinephron segment diuretic therapy (MSDT) has been recommended in severe diuretic resistance with only expert opinion and case-level evidence. The purpose of this study was to investigate the safety and efficacy of MSDT, combining 4 diuretic classes, in acute heart failure (AHF) complicated by diuretic resistance.
METHODS AND RESULTS
A retrospective analysis was conducted in patients hospitalized with AHF at a single medical center who received MSDT, including concomitant carbonic anhydrase inhibitor, loop, thiazide, and mineralocorticoid receptor antagonist diuretics. Subjects served as their own controls with efficacy evaluated as urine output and weight change before and after MSDT. Serum chemistries, renal replacement therapies, and in-hospital mortality were evaluated for safety. Patients with severe diuretic resistance before MSDT were analyzed as a subcohort. A total of 167 patients with AHF and diuretic resistance received MSDT. MSDT was associated with increased median 24-hour urine output in the first day of therapy compared with the previous day (2.16 L [0.95-4.14 L] to 3.08 L [1.74-4.86 L], P = .003) in the total cohort and in the Severe diuretic resistance cohort (0.91 L [0.43-1.43 L] to 2.08 L [1.13-3.96 L], P < .001). The median cumulative weight loss at day 7 or discharge was -7.4 kg (-15.3 to -3.4 kg) (P = .02). Neither serum sodium, chloride, potassium, bicarbonate, or creatinine changed significantly relative to baseline (P > .05 for all).
CONCLUSIONS
In an AHF cohort with diuretic resistance, MSDT was associated with increased diuresis without changes in serum chemistries or kidney function. Prospective studies of MSDT in AHF and diuretic resistance are warranted.
Topics: Acute Disease; Diuretics; Heart Failure; Humans; Mineralocorticoid Receptor Antagonists; Prospective Studies; Retrospective Studies; Sodium Potassium Chloride Symporter Inhibitors
PubMed: 34403831
DOI: 10.1016/j.cardfail.2021.07.016 -
Natural Product Research Jun 2019The diuretic activity of ethanolic extract of was investigated in rats. A single oral dose of 500 mg/kg of extract were given to rats, after 24 h, urine volume, its...
The diuretic activity of ethanolic extract of was investigated in rats. A single oral dose of 500 mg/kg of extract were given to rats, after 24 h, urine volume, its sodium and potassium concentrations were estimated. Treatment with extract caused a significant increase in tested parameters as compared to their corresponding controls, < 0.05.
Topics: Administration, Oral; Animals; Diuretics; Drug Evaluation, Preclinical; Ethanol; Male; Panicum; Plant Extracts; Plant Roots; Potassium; Rats, Wistar; Rhizome; Sodium
PubMed: 29417837
DOI: 10.1080/14786419.2018.1437440 -
European Heart Journal Feb 2023
Topics: Humans; Sodium Chloride Symporter Inhibitors; Thiazides; Heart Failure; Diuretics
PubMed: 36583255
DOI: 10.1093/eurheartj/ehac784 -
Diuretic downsides--but in low doses they still seem among the best authenticated antihypertensives.Cardiovascular Drugs and Therapy Aug 2000Diuretics in low doses have the greatest support among current available antihypertensives in that they have been shown to reduce total mortality, coronary mortality,... (Review)
Review
Diuretics in low doses have the greatest support among current available antihypertensives in that they have been shown to reduce total mortality, coronary mortality, stroke, and congestive heart failure in an important meta-analysis by Psaty. Recently, Messerli has linked longterm diuretic use to renal cell carcinoma in women. In some patients, diuretic use leads to increasing blood cholesterol and blood sugar levels. Impotence is a recognized side effect, with rates rising about twofold with low-dose chlorthalidone and fourfold with a higher dose. Certain population groups such as younger (<60 years) white males often do not respond to low-dose diuretic therapy with an adequate blood pressure fall. In females of a similar age group, Messerli calculates that prolonged diuretic therapy will prevent only one stroke and no coronary events nor any deaths for every renal cell carcinoma that is provoked. Despite these evident problems, the outcome data on hard endpoints in trials with initial low-dose diuretic therapy remain valid and convincing. Thus, it is argued, low- but not high-dose diuretics retain their primacy in the ranking of antihypertensive therapy.
Topics: Antihypertensive Agents; Diuretics; Dose-Response Relationship, Drug; Erectile Dysfunction; Female; Humans; Hypercholesterolemia; Hypertension; Male; Middle Aged; Neoplasms
PubMed: 10999647
DOI: 10.1023/a:1007864216398 -
Journal of Clinical Pharmacology 1986New diuretics introduced into clinical medicine during the past decade include potent new loop diuretics such as bumetanide and piretanide, the uricosuric... (Review)
Review
New diuretics introduced into clinical medicine during the past decade include potent new loop diuretics such as bumetanide and piretanide, the uricosuric indanyloxyacetic acid derivative indacrinone, and a new generation of sulfamoyl diuretics such as indapamide and xipamide, which are recommended primarily for the treatment of hypertension. Pharmacokinetic studies of individual diuretics have demonstrated that the diuretic and natriuretic responses to the newer agents generally follow the plasma drug concentration-time curves and urinary drug excretion rates. Therapeutic monitoring can therefore be achieved in most patients with edema or hypertension by close clinical observation and laboratory analysis of plasma electrolyte and creatinine concentrations and urinary electrolyte excretion rates. Interest in the mechanisms involved in the renal and extrarenal vascular actions of the newer diuretics has led to a better understanding of how changes in venous compliance, peripheral vascular resistance, and renal blood flow distribution may contribute to the overall therapeutic response to these agents, especially in patients with severe congestive heart failure, renal insufficiency with low glomerular filtration rates, and hypertension with cardiorenal complications. Adverse reactions to modern diuretics, which are mainly an extension of their renal pharmacodynamic effects, have proved to be minimal, provided that the dosage is adjusted to meet but not exceed individual patient requirements. However, the long-term consequences of prolonged periods of diuretic-induced alterations in plasma potassium levels, and metabolic effects that include elevated blood lipids, are still under investigation.
Topics: Diuretics; Humans
PubMed: 3540029
DOI: 10.1002/j.1552-4604.1986.tb02951.x -
Cleveland Clinic Journal of Medicine Jun 2006The pathophysiology of sodium and water retention in heart failure is characterized by a complex interplay of hemodynamic and neurohumoral factors. Relative arterial... (Review)
Review
The pathophysiology of sodium and water retention in heart failure is characterized by a complex interplay of hemodynamic and neurohumoral factors. Relative arterial underfilling is an important signal that triggers heart failure-related sodium and water retention. The response to perceived arterial underfilling is modulated by the level of neurohormonal activation, the degree of renal vasoconstriction, and the extent to which renal perfusion pressure is reduced. Sodium retention can also be exceeded by water retention, with the result being dilutional hyponatremia. Sodium and water retention in heart failure also function to dampen the natriuretic response to diuretic therapy. The attenuated response to diuretics in heart failure is both disease-specific and separately influenced by the rate and extent of diuretic absorption, the rapidity of diuretic tubular delivery, and diuretic-related hypertrophic structural changes that surface in the distal tubule.
Topics: Body Water; Diuretics; Edema; Glomerular Filtration Rate; Heart Failure; Humans; Sodium; Water-Electrolyte Imbalance
PubMed: 16786906
DOI: 10.3949/ccjm.73.suppl_2.s2 -
Expert Opinion on Drug Safety Mar 2010As with all potent therapeutic agents, the use of diuretic compounds has been linked with several adverse effects that may reduce quality of life and patient compliance... (Review)
Review
IMPORTANCE OF THE FIELD
As with all potent therapeutic agents, the use of diuretic compounds has been linked with several adverse effects that may reduce quality of life and patient compliance and, in some cases, may be associated with considerable morbidity and mortality. Among the various types of adverse effects, disturbances of electrolyte and acid-base balance are perhaps the most common, and some of them are the aetiological factors of other side effects (i.e., hypokalaemia causing ventricular arrhythmias or glucose intolerance). The mechanism and site of action and, therefore, the pharmacological effects of each diuretic class largely determine the specific electrolyte or acid-base abnormalities that will accompany the use of each diuretic agent.
AREAS COVERED IN THE REVIEW
This article reviews the major electrolyte disturbances (hypokalaemia, hyperkalaemia, hyponatraemia, disorders of magnesium and calcium balance), as well as the acid-base abnormalities complicating the use of the various diuretic agents.
WHAT THE READER WILL GAIN
The reader will gain insights into the pathogenesis of the diuretic-induced electrolyte and acid-base disorders together with considerations for their prevention and treatment.
TAKE HOME MESSAGE
Knowledge of the pharmacologic properties of each diuretic class and appropriate monitoring of patients under diuretic treatment represent the most important strategies to prevent the development of diuretic-related adverse events and their consequences.
Topics: Acid-Base Equilibrium; Acid-Base Imbalance; Animals; Diuretics; Humans; Water-Electrolyte Imbalance
PubMed: 20095916
DOI: 10.1517/14740330903499257 -
American Journal of Cardiovascular... Oct 2013Patients with decompensated heart failure frequently present with volume overload, which is conventionally treated with diuretics. These drugs have been associated with... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Patients with decompensated heart failure frequently present with volume overload, which is conventionally treated with diuretics. These drugs have been associated with several adverse effects, including increased mortality, leading some clinicians to propose ultrafiltration as a safe alternative to remove sodium and water.
OBJECTIVE
The objective of our study was to compare the safety and efficacy of ultrafiltration and conventional intravenous diuretic therapy for patients with acute heart failure and volume overload.
DATA SOURCES
We searched the following databases through November 2012: Cochrane Library (1993-), PubMed (1988-), OVID (1984-), EBSCO (1984-), CBM (1978-), VIP (1989-), and CNKI (1979-). In addition, we manually searched relevant references and review articles.
STUDY SELECTION
Randomized controlled trials comparing the efficacy of ultrafiltration and intravenous diuretics in patients diagnosed with hypervolemic acute heart failure were included. Five trials were found to satisfy all the inclusion criteria.
STUDY APPRAISAL AND SYNTHESIS METHODS
Two reviewers independently determined study eligibility, assessed methodological quality and extracted the data. We analyzed the data and pooled them, when appropriate, using Revman 5.0. We assessed the risk of bias in the included studies using guidelines in the Cochrane Handbook 5.0 for Systematic Reviews of Interventions, taking into account sequence generation, allocation concealment, blinding, incomplete outcome data, and selective outcome reporting.
RESULTS
Data from the initial phase of five trials involving 477 participants were included. Meta-analysis of the pooled data showed that ultrafiltration was significantly better than diuretic drugs based on 48-h weight loss (Z = 3.72; P < 0.001, weighted mean difference [WMD] = 1.25 kg, 95 % CI 0.59-1.91) and based on 48-h fluid removal (Z = 4.23; P < 0.001, WMD = 1.06 L, 95 % CI 0.57-1.56). Adverse events did not differ significantly between the ultrafiltration and intravenous diuretic treatment groups.
LIMITATIONS
There are several limitations to our review, including publication bias and selection bias. Our review included only a few studies involving relatively few participants.
CONCLUSIONS
The available evidence suggests that early ultrafiltration is safe and effective for patients with hypervolemic acute heart failure. It allows greater fluid removal and weight loss by 48 h than do intravenous diuretics, with no significant increase in adverse effects.
Topics: Acute Disease; Administration, Intravenous; Diuretics; Heart Failure; Humans; Randomized Controlled Trials as Topic; Time Factors; Ultrafiltration; Weight Loss
PubMed: 23801482
DOI: 10.1007/s40256-013-0034-3 -
Current Hypertension Reports Aug 2008For decades, diuretic therapy has been a cornerstone in treating hypertension, an approach supported by multiple randomized controlled trials demonstrating reduced... (Review)
Review
For decades, diuretic therapy has been a cornerstone in treating hypertension, an approach supported by multiple randomized controlled trials demonstrating reduced morbidity and mortality from cardiovascular events. Yet controversy persists regarding the potential detrimental metabolic effects and side effects of diuretic agents. Within the risk-benefit debates about diuretic therapy is a second dialogue regarding the best thiazide or thiazidelike agent to prescribe. Proponents of chlorthalidone emphasize the demonstrated reductions in cardiovascular events reported from multiple classic trials and its longer half-life, whereas opponents point to its limited availability in low-dose forms and comparable favorable results from hydrochlorothiazide-based therapy to discredit claims of superiority. This review presents the data available on both sides of this issue to help the reader decide which claims are most valid, and offers recommendations for treatment.
Topics: Chlorthalidone; Clinical Trials as Topic; Diuretics; Dose-Response Relationship, Drug; Half-Life; Humans; Hypertension
PubMed: 18625158
DOI: 10.1007/s11906-008-0054-6