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Ο δωδεκάλογος του διουρητικού.

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GirousisN:
Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή ΕίσοδοςΚαλησπέρα. Θα μπορουσατε μήπως να δώσετε μια εξήγηση για το σχόλιο 5? Δηλαδή τι ακριβως συμβαίνει σε επίπεδο νεφρώνα και δεν έχουμε δράση των θειαζιδικών σε αυτές τις τιμές του GFR?  Ευχαριστω

--- Τέλος παράθεσης ---

Οι κατευθυντήριες οδηγίες του NKF / K-DOQI για τη χρήση διουρητικών στη ΧΝΝ, αποτελεί και μια καλή επανάληψη για όλους μας.Αναλύονται μεταξύ άλλων η φυσιολογία, η φαρμακολογία και η αντίσταση στη δράση τους.

Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος

Κάποια ενδιαφέροντα σημεία από ένα χρησιμότατο άρθρο

One factor that limits the delivery of diuretics to their sites of action in the tubular lumen in patients with CRI is a reduction in renal blood flow.
Τhe increased plasma levels of organic anions and urate, and the metabolic acidosis that are characteristic feature of CRI, may be a second set of factors that contribute to diuretic resistance in CRI by impairing proximal tubule secretion of diuretics and hence impairing their delivery into tubular fluid to reach their active site in the nephron.

Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος

Argirios Argiriou:
Τον πίνακα αυτόν τον δημοσίευσε συνάδελφος στις 21/09/2017  στην ομάδα ΓΕΝΙΚΟΙ / ΟΙΚΟΓΕΝΕΙΑΚΟΙ ΙΑΤΡΟΙ ΕΛΛΑΔΑΣ στο facebook,

και μια άλλη συνάδελφος έγραψε σαν σχόλιο ένα πολύ χρήσιμο μνημονικό κανόνα:

αλλωστε ξερετε πως πηρε το ονομα του το lasix. lasts six (hours)

Argirios Argiriou:

Argirios Argiriou:
Red Whale, 2020
Increased ankle swelling in those with known heart failure

Επισυνάπτεται και έχει και αρκετά ενδιαφέροντα στοιχεία και τις ιδιότητες των διουρητικών:

So, what are our top ten diuretic prescribing messages from this article?

1. Dose effect is ‘all-or-nothing’. These drugs behave like an on/off switch for diuresis, and the dose at
which this switch is flicked will be different for different people. If the dose is adequate for an
individual then a significant diuresis should be noticed within 4–6 hours.
(This is practice-changing for a few of the Red Whale team. Consider monitoring urine output after
starting a new dose to check this! Maybe we should be adding an alert to their medication screen,
‘40mg works for Mrs Jones’, once we have established the correct dose?).

2. If the patient has a good response to a particular dose then giving more will not cause a bigger
diuresis. As renal function declines, the on/off switch might shift to higher doses, so we may need
to review the dose if drug effect decreases over time.

3. This means there is no point in prescribing variable doses (e.g. 40mg in the morning and 20mg at
lunch, or 40mg normally but 80mg when oedema worse).

4. If more diuresis is needed, you have 2 choices:
• Give a second dose at least 6 hours later to prolong the effect.
• Add a second class of diuretic on top

5. If you want to achieve a weaker diuretic effect, try a different class of diuretic rather than
prescribing a subtherapeutic dose of a loop diuretic, e.g. thiazides cause only 25% of the urine
output expected from a loop diuretic. Potassium-sparing diuretics on their own are only 3% as
effective as loop diuretics.

6. ACEi, ARBs and NSAIDS can all reduce the effectiveness of loop diuretics through their effect on
the kidney (I think I did know about the NSAID risk, but ACEi? Total DEN for me!).

7. Equivalent doses of loop diuretics (useful for those drug shortage dilemmas!): 80mg PO
furosemide ≈ 20mg PO torsemide ≈ 1mg PO bumetanide.

8. Intestinal oedema does NOT affect absorption of oral loop diuretics significantly – it may be
slower, but overall effect will be equivalent.

9. Which one is best? There is an absence of good head-to-head studies on this, so we just don’t
know.

10. Self-weighing really can help (from SIGN guidance on heart failure): patients weigh themselves
daily to monitor fluid balance (on waking, after voiding, before dressing, before eating). They
notify the GP/heart failure nurse if they gain more than 1.5–2kg (3–4lbs) over 2d.
This can be used either to allow pulsed dosing of diuretics, or to allow the addition of a second
dose of diuretic to trigger greater diuresis.

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