Medium strength diuretics. What are diuretics and how are they classified? Indications for use

Diuretics are commonly called synthetic drugs that inhibit the reabsorption of salts and water, increasing their excretion in the urine, and also increases the rate of its formation, thereby reducing the total amount of fluid in the body. Since these drugs are widely used in various branches of medicine, the list of diuretic drugs is growing every year. All diuretics can be divided into 4 groups.

Diuretics - names of drug groups

• Saluretics;
• Potassium-sparing drugs;
• Osmotic agents;
• Calcium-sparing tablets.

Diuretics - list of saluretics

It is quite difficult to remember all the diuretic names of saluretics, since this general concept combines 3 types of subgroups of drugs. They are prescribed for glaucoma and hypertension.

Saluretics (diuretics) list of subgroups of drugs:

1. loop diuretics;
2. carbonic anhydrase inhibitors.

Trade names of diuretics included in these groups:

• Chlorthalidone,
• Bumetonida,
• Diakarb,
• Hydrochlorothiazide,
• Bumetonida,
• Fonurit,
• Indapamed,
• Furosemide,
• Acetamoc,
• Chlorthizide,
• Ethacrynic acid,
• Dehydratin,
• Priretanide.

Potassium-sparing diuretics, drug names

Potassium-sparing diuretics are prescribed for the treatment of patients with hypertension in combination with other drugs. Potassium-sparing diuretics are usually combined with thiazide and loop drugs. The main effect of potassium-sparing tablets, as the name suggests, is to prevent the removal of potassium salts along with the removal of excess fluid from the body when taking strong diuretics.

Pharmacological names of diuretic drugs of this group:

• Triamur,
• Veroshpiron,
• Amiloride,
• Spironolactone,
• Triamterene,
• Aldactone.

Osmotic agents - list of diuretics

Today, osmotic agents have the shortest list of diuretics. Their names boil down to:

• Sorbitol,
• Manitou,
• Urea.

The peculiarity of diuretics, the names of which are given above, is that they are able to quickly reduce plasma pressure, due to which water is removed from the swollen area. This mechanism of action of osmotic drugs is the reason for their frequent prescription for edema of the larynx, lungs, brain, glaucoma, peritonitis, pill poisoning, burns and sepsis.

From the above list of osmotic diuretics, Manit is most often used, since it has the longest duration of action and the fewest side effects.

Calcium-sparing diuretics, names of drugs and their features

This group of diuretics is especially recommended for elderly people, patients with osteoporosis and children. That is, for all those for whom the loss of calcium in the body, and therefore in the bones, is fraught with fractures in the future. In addition, calcium-sparing tablets have shown good results in the treatment of postmenopausal women with hypertension and in the treatment of IDDM (some patients with this form of diabetes feel worse when calcium levels decrease). In addition, this group of drugs has one interesting feature - they catalyze the actions of other diuretics when taken together, which makes it possible to achieve a high effect without increasing the dosage.

Calcium-sparing diuretics (tablets) drug names:

• Oxodoline,
• Hygroton,
• Hypothiazide,
• Hydrochlorothiazide,
• Tenzar,
• Acrylamide,
• Retapres,
• Akuter-Sanovel,
• Pamid,
• Arindap,
• Lorvas,
• Arifon,
• Ionic,
• Indap,
• Indiur,
• Indapres,
• Indapsan and others.

Diuretics are diuretic drugs that act on different parts of the kidney, increasing urine output. The classification of diuretics in pharmacology is very broad; all drugs are divided into groups and differ in composition, mechanism of action on the body, time of onset and duration of the diuretic effect. It is important to know which drugs are classified as diuretics, let’s look at this.

Clinical pharmacology

Each day, the kidneys excrete approximately 1.5 liters of urine, which passes through various glomerular filtration systems, the near and far tubules, and the loop of Henle. Next, the urine goes directly into the ureter, and then into the bladder, from where it is discharged. In the structures of the tubules, almost 90% of the molecules of liquid and salts that the human body needs are reabsorbed. Taking into account these principles of the urinary system, we can conclude that diuretics have a direct effect on the function of urine production by the kidneys and change their regulation, increasing glomerular filtration. Almost all types of diuretics act by blocking the reabsorption of salts and water in individual tubules.

Classification by mechanism of action

• drugs that work at the level of renal tubular cells, for example, mercury diuretics (Eplerenone, Diacarb, Indapamide, Bumetonide);
• drugs that increase the process of renal blood circulation (“Aminophylline”, “Zufillin”);
• preparations from medicinal plants - birch buds, torment leaves, strawberry fruits.

Table of classification of diuretics by composition:

Loop diuretics

Loop diuretics affect the reabsorption of potassium, reducing it, which leads to increased excretion of potassium in urine. Most often, medications are recommended to be taken orally on an empty stomach. There is also the option of intramuscular and intravenous administration, due to which the effect occurs a little faster. Loop diuretics should be taken no more than 2 times per day.

Loop diuretics are potent and compatible with other diuretics and cardiovascular medications. Taking it together with non-steroidal anti-inflammatory tablets is prohibited, because diuretics will enhance the effect of other drugs on the body.

Thiazide

The thiazide type of diuretics are diuretics of moderate effect, and they differ from loop ones in that they minimize the excretion of potassium and maximize the concentration of sodium in the kidney, which makes it possible to enhance the excretion of potassium. Medicines have a beneficial effect on the body and do not require the patient to strictly adhere to restrictions on salt intake.

Potassium-sparing

The clinical pharmacology of potassium-sparing diuretics is that the diuretic acts on the distal renal tubules, in which it either reduces potassium secretion or is an aldosterone antagonist. Potassium-sparing medications are used for hypertension to lower blood pressure. However, these diuretics have a mild effect, so using them alone to treat high blood pressure will not be very effective. Therefore, potassium-preserving tablets are not taken alone, but in combination with loop and thiazide diuretics to avoid side effects in the form of low potassium content.

Osmotic

The principle of operation of osmotic diuretics is that they increase the osmotic pressure in the blood plasma, due to which fluid is removed from swollen tissues and the volume of blood that circulates increases. This reduces the reabsorption of sodium and chlorine. When prescribing these diuretics, you should pay attention to the person’s side diseases, since they can have a bad effect on liver and kidney diseases.

Groups of diuretic drugs by strength

A classification is also made according to the strength of influence, distinguishing the following types of diuretics:

• lungs;
• average;
• strong.

Mild diuretics

Osmotic drugs remove water from edema.

Light drugs are used in gynecology to remove swelling of the patient’s legs and arms during pregnancy. Doctors often prescribe osmotic medications, because their main effect is to remove water from edema. Mild diuretics are also used to lower blood pressure in children and the elderly. Diuretics are often prescribed to preserve potassium in the body. Various decoctions of medicinal plants are also mild diuretics. Medicines in this group have a mild diuretic effect and have no side effects.

Medium diuretics

Medium diuretics include thiazide medications. Their effect is observed 20-60 minutes after application and lasts for 7-15 hours. Used for complex therapy of high blood pressure (excluding beta blockers), chronic swelling caused by acute heart failure, diabetes, kidney stones and glaucoma.

Diuretics include such potent diuretics

1. Lasix, which can be taken either orally or by injection. Its main advantage is quick results.
2. "Spironolactone", which is used for a variety of edema.
3. "Mannitol", produced in powder form for use in cases of swelling of the brain and lungs, and in case of chemical poisoning.

The drug begins to act within a few minutes and lasts up to 2-8 hours.

The effect of rapid-acting diuretics begins within a few minutes and lasts up to 2-8 hours. List of diuretics: Furosemide, Uregit, Mannitol. Diuretics of average effect give results after 1-4 hours, and their effect is observed for 9-24 hours. Names of drugs: “Dichlorothiazide”, “Diacarb”, “Triamtren”. The effect of slow diuretics occurs 2-4 days after use and lasts approximately 5-7 days. The most well-known remedy in this group is Spironolactone.

Diuretics for edema

During the treatment of chronic swelling, the following strong diuretics are often used: Furosemide, Piretanide, Torasemide. They should be taken in short courses, taking breaks in order to prevent addiction and subsequently a decrease in the effect of the diuretic. Most often, treatment follows the following scheme: diuretics are taken 5-20 mg per day until the swelling subsides. Then they take a break for several weeks, and then resume treatment.

In addition to potent diuretics, moderate-effect diuretics are also used to treat edema. Examples: “Polythiazide”, “Clopamide”, “Metozolon”, “Hydrochlorothiazide”. It is recommended to take the drugs at a dose of 25 mg per day. Treatment should be carried out for a long time, without prescribing breaks.

In situations where the edema is not severe, experts recommend light (potassium-sparing) diuretics: Amiloride, Spironolactone, Triamterone. The drugs are prescribed at a dosage of 200 mg per day, divided into 2-3 doses. The duration of therapy is several weeks, then the course is resumed if necessary after 2 weeks.

To date, there is no classification of diuretics that would take into account all aspects of the action of these types of medications. So, groups can be divided by:

• chemical structure;
• place of action;
• mechanism of action;
• force of action;
• speed of effects;
• duration of exposure;
• by side effects.

The very first classification of diuretics was based on differences in the chemical structure of the drugs. Then there was an attempt to generalize the types of diuretics according to the nature of their effect on the kidneys. However, some diuretics have extrarenal effects. Also unsuccessful was an attempt to classify diuretics by which part of the nephron they affect, since osmotic drugs, ethacrynic acid, Furosemide, Xanthines and others act not on a specific part of the nephron, but throughout its entire length. Due to these characteristics of diuretics, classification according to the mechanism of action is the most rational.

When treating a patient, it is no less important, from a clinical point of view, to classify diuretics according to the duration of exposure, the speed of onset of the effect, and also the strength of action.

Thiazide diuretics

Thiazide and thiazide-like diuretics are widely used due to their effectiveness and the fact that their use does not require too strict restriction of salt intake by patients with moderate and mild forms of heart failure.

In fact, thiazide diuretics are diuretics of medium potency, the main difference of which from loop drugs is a decrease in calcium excretion and an increase in sodium concentration in the distal nephron, which allows increasing the exchange of sodium for potassium, increasing the excretion of the latter.

When prescribing thiazide diuretics, the list of drugs mainly consists of Hydrochlorothiazide and Chlorothiazide, after taking which the maximum concentration of active substances in the body is reached after 4 hours and does not decrease for 12 hours.

Many derivative drugs have been created on the basis of Chlorthiazide, but it is most convenient to prescribe Chlorthalidone, since this thiazide diuretic is taken only once a day, while the same Chlorthiazide must be taken 500 mg every 6 hours.

Loop diuretics

Loop diuretics are diuretic drugs, which include drugs such as: Torsemide, Piretanide, Bumetonide, Ethacrynic acid and Furosemide. Typically, these drugs are taken either orally on an empty stomach (in which case their absorption is about 65%) or intramuscularly/intravenously (in this application, absorption reaches 95%, due to good binding to blood proteins).

Loop diuretics differ in their mechanism of action from thiazide diuretics in that they reduce the reabsorption of calcium, thereby increasing the excretion of calcium in the urine from the patient’s body. These drugs should be taken no more than 2 times a day, despite the fact that half-elimination from the blood occurs on average in 60 minutes.

When prescribing loop diuretics together with other drugs, one should take into account the fact that they combine well with both cardiovascular drugs and other diuretics. But simultaneous use with nephrotoxic and ototoxic drugs, as well as with non-steroidal anti-inflammatory drugs, is contraindicated, since loop diuretics in this case will increase the undesirable effects of the former on the patient, and in the case of non-steroidal anti-inflammatory drugs, the diuretic will act as a pharmacodynamic antagonist.

Potassium-sparing diuretics

To conserve potassium in the human body, the diuretic must act on the distal tubule, where it either inhibits potassium secretion or acts as a direct aldosterone antagonist. Diuretics that do not remove potassium are often prescribed for hypertension in order to lower blood pressure, but you should be aware that this group of diuretics has a weak effect, so its prescription as the only treatment for high blood pressure is ineffective.

Therefore, diuretics that do not remove potassium are used not alone, but in combination with thiazide and loop diuretics to prevent hypokalemia. The most commonly used potassium-sparing diuretics are Veroshpiron, Aldactone, Spironolactone, Amiloride and Triampur.

Unlike potassium-sparing diuretics, potassium-sparing ones have one serious side effect - the risk of hyperkalemia, especially in patients with diabetes mellitus, renal failure, or if these drugs are combined with ARB inhibitors, ACE inhibitors, or potassium supplements. In addition, if the prescribed potassium-sparing drugs were hormonal antagonists of aldosteronam, then gynecomastia and impotence in men and menstruation disorders, pain in the mammary glands and postmenopausal bleeding in women can be added to the negative consequences.

Osmotic diuretics

The mechanism of action of osmotic diuretics is based on an increase in osmotic pressure in the blood plasma, as a result of which water begins to be extracted from edematous tissues, and as a result, the volume of circulating blood increases. As a result of an increase in the total volume of circulating blood, there is an increase in blood flow in the glomeruli of the kidneys, filtration increases, and there is a disruption in the functioning of the countercurrent-turning system of the loop of Henle, which leads to the suppression of the passive reabsorption of chlorine and sodium in the ascending limb of the loop of Henle.

Osmotic diuretics include Urea, Sorbitol, Mannitol. Today, of the listed drugs, Mannitol is most often used, since Sorbitol and Urea have a shorter duration of action and have a weaker effect. In addition, it is worth considering the patient’s side diseases, since the same Urea cannot be prescribed to patients with impaired liver or kidney function.

Side effects of taking osmotic diuretics include increased blood pressure, vomiting, the risk of developing bilirubin encephalopathy, nausea, headaches, and when using Urea, an increase in nitrogen levels in the blood.

Mild diuretics

Mild diuretics have found wide use in gynecology and pediatrics to combat swelling of the arms and legs in pregnant women, to normalize slightly elevated blood pressure in children and to treat the elderly. In the first case, osmotic drugs can be used as mild diuretics, since their main effect is aimed specifically at removing fluid from edematous tissues. Children and elderly people are often prescribed potassium-sparing diuretics as a weak diuretic, which in most cases is sufficient when it is necessary to lower a child’s blood pressure by 10-20 mmRs. In elderly people, due to changes in the course of biochemical processes, which in all respects belong to mild diuretics, are able to provide the maximum possible positive result.

It should be noted that it is better to give preference to those drugs that fall under the “mild” classification and do not have various hormonal side effects, which is especially important when it comes to small children and pregnant women. Also, various herbal infusions can be classified as mild diuretics.

Strong diuretics

Unlike mild diuretics, which have been used in folk medicine in the form of infusions from various herbs for quite a long time, strong diuretic synthetic drugs were created relatively recently, but have already become widespread in the treatment of various diseases.

Today, the most powerful diuretics are the following drugs:

• Lasix;
• Spironolactone;

Lasix can be used either parenterally or orally. The undoubted advantage of this remedy is the rapid onset of a positive effect after its use. For example, if Lasix was taken orally, improvement will occur within one hour, and if administered parenterally, within a few minutes. At the same time, the duration of action of this diuretic when taken orally reaches 8 hours, and when administered intravenously - only three.

The diuretic effect of another strong diuretic drug, Spironolactone, used for edema of various origins, including cardiac edema, usually occurs on the 3rd day of taking the medication. However, this time can be greatly reduced by prescribing Flurosemide or Hypothiazide with Spironolactone.

Manitol is available in the form of a dry powder and is considered one of the most powerful diuretics used for edema of the brain, lungs, heart and barbiturate poisoning.

Combination diuretics

Combination diuretic drugs include:

1. Vero-Triamtezid;
2. diazide;
3. Diursan;
4. Diursan mite;
5. Isobar;
6. Lasilactone;
7. Moduretic;
8. Thialoride;
9. Triam-Co;
10. Triampur compositum;
11. Triamtezide;
12. Triamtel;
13. Furesis compositum;
14. Furo-Aldopur;
15. Ecodurex;
16. Aldactone Saltucin;
17. Amyloside;
18. Amiloretic;
19. Amiloride + Hydrochlorothiazide;
20. Amitride;
21. Amitridite;
22. Apo-Triazide.

All of these combined diuretic drugs have both a hypotensive and diuretic effect. The advantage of combined drugs is the speed of onset of positive changes after taking them (from 1 to 3 hours) and maintaining the achieved effect for 7 to 9 hours.

Combined diuretics are mainly used for chronic venous insufficiency, toxicosis in the last weeks of pregnancy, liver cirrhosis, nephrotic syndrome, CHF, as well as arterial hypertension.

Diuretic, non-calcium excreting

Diuretic tablets that do not remove calcium are prescribed to those patients who have high blood pressure combined with osteoporosis. This is a necessary measure to prevent the progression of osteoporosis in patients, and as a consequence, the appearance of new fractures. Loop and potassium-sparing diuretics wash away calcium, while thiazide diuretics, on the contrary, reduce the excretion of calcium ions in the urine. That is why patients with osteoporosis are prescribed only thiazide-like and thiazide diuretics. However, calcium-sparing diuretics are necessary not only for people suffering from osteoporosis, but also for other people at high risk of developing ORA injuries, for example, older people. Studies have shown that people taking thiazide-like diuretics to treat chronic hypertension are less likely to have fractures than those prescribed other types of diuretics.

But, despite the described advantages of calcium-sparing diuretics, they may be contraindicated in some groups of patients, since their use is associated with an increase in the excretion of magnesium and potassium from the body, which means they cannot be prescribed to patients with hyperuricemia, gout, hypokalemia, etc.

Antihypertensive diuretics

A rather promising direction in the treatment of hypertension in patients is the use of hyotensive diuretics. And the point is not only that almost all diuretics are capable of lowering blood pressure, in some cases not inferior in effectiveness to highly specialized drugs prescribed for the treatment of chronic forms of hypertension, but also that treatment with antihypertensive diuretics compared, for example, with b blockers , will cost the patient 9-15 times less, which is important, given the fact that mainly the group of people suffering from hypertension are pensioners, whose financial wealth in most cases does not allow them to pay for expensive long-term treatment.

When taking diuretics, the hypotensive effect is achieved due to the fact that at the initial stage of treatment there is a decrease in the amount of circulating blood and cardiac output (the supply of sodium chlorides is depleted), and although after a few months the blood flow is normalized, the blood vessels by this time reduce peripheral resistance, thereby maintaining antihypertensive effect achieved during treatment.

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Diuretics increase urine output (diuresis)

- filtration enhancement(formation of primary urine)

- inhibition of electrolyte reabsorption processes(primarily Na +, Cl -) and water in kidney tubules(formation of secondary urine).

In medical practice, they are used for edema of various etiologies (acute and chronic). In addition, diuretics are used in case of poisoning with drugs and other chemical compounds to accelerate their elimination from the body (the so-called forced diuresis), and also as antihypertensive agents.

Classification of diuretics:

By localization of action in the nephron:

Thiazide– act on the initial part of the distal renal tubules (hydrochlorothiazide).

Thiazide-like– act on the initial part of the distal parts of the renal tubules (clopamide (brinaldix), indapamide (arifon), chlorthalidone (oxodoline)).

Loop diuretics– act on the ascending limb of the loop of Henle (furosemide (Lasix), bumetanide (Bufenox), ethacrynic acid (Uregit)).

Potassium-sparing diuretics– act on the distal tubules and collecting ducts (triamterene (pterophen), amiloride, spironolactone (aldactone, veroshpiron).

Osmotic– act on the proximal tubules, the descending part of the loop of Henle, collecting ducts (mannitol (mannitol), sorbitol, urea).

Carbonic anhydrase inhibitors– act on the proximal tubules

(diacarb (acetazolamide)).

Aquaretics– demeclocin (ADH antagonist).

Herbs that have a diuretic effect– bearberry leaf (folium Uvaeursi), lingonberry leaf (folium Vitisidaei), birch buds (gemmae Betulae), horsetail grass (herba Equiseti Arvensis), juniper fruits (fructus Juniperi).

Medicines with a diuretic effect: cardiac glycosides,

xanthines – enhance glomerular filtration;

By strength:

Strong(cause excretion of 15-25% of filtered sodium) - loop diuretics, osmotic (natriuresis is not great).

Medium strength(excretion of 5-10% filtered sodium) – thiazide, thiazide-like diuretics.

Weak(excretion not 5%) – diacarb (fonurite), potassium-sparing (triamterene, amiloride, spironolactone).

By the nature of the effect:

Hydrouretics

Saluretics

Potassium-sparing

Carbonic anhydrase inhibitors.

By speed and duration of action:

- quick and short-lasting effect: loop, osmotic.

- medium strength and duration: thiazide, potassium-sparing (triamterene),

carbonic anhydrase inhibitors, xanthines.

- delayed and long-acting: thiazide-like, potassium-sparing (spironolactone).

Comparative characteristics, distinctive properties and features of the prescription of diuretics are presented in Table 1.

Table 1

Comparative characteristics of diuretics

A drug		Destination Features
	Dehydration (after IV administration, it initially increases the osmotic pressure of the blood, i.e., “pulling fluid” from the tissues, useful for cerebral edema) => an increase in blood volume, decreasing as development progresses diuretic effect Increases BCC Alkalinizes urine They increase the osmotic pressure of blood and primary urine, causing tissue dehydration, which reduces water reabsorption; increase renal blood circulation and glomerular filtration.	Used for local edema (brain, larynx, lungs) Not used for cardiac vascular insufficiency. It is used in acute hemolytic conditions to prevent the precipitation of proteins and hemoglobin. Acute poisoning with water-soluble poisons
Furosemide	prostacyclins and reduces preload. Sharply removes K+ and increases the threshold of sensitivity to cardiac glycosides. Changes the ionic balance in the lymph of the inner ear. Improves metabolism in damaged brain tissue. They block the sulfhydryl groups of enzymes in the loop of Henle, which leads to decreases the reabsorption of Na +, Mg 2+, K + ions and reduces the reabsorption of H 2 O. Promotes the excretion of K +, Mg 2+, Ca 2+, Na + ions.	Prescribed for pulmonary edema background of pulmonary-cardiac insufficiency. Avoid joint use. Causes an ototoxic effect; exclude combination with aminoglycoside antibiotics. Used for traumatic brain injury. Arterial hypertension, hypertensive crisis; Liver cirrhosis with portal hypertension and ascites; Acute poisoning (forced diuresis);
Hydrochlorothiazide	Increases Ca 2+ reabsorption Flushes out Na+ from vascular wall. Retains urinary They inhibit the activity of Na + -K + -ATPase, succinate dehydrogenase, and bind carbonic anhydrase. As a result, the supply of energy to the sodium pump is disrupted. Inhibit reabsorption Na +, Cl – ions and water. Promote elimination ions K + and Mg 2+ and retain Ca 2+ ions.	Combine with furosemide, excreting Ca 2+ Prescribed for hypertension There is a danger of provoking gout. Diabetes insipidus; Subcompensated glaucoma; Arterial hypertension (in complex therapy) Congestive heart failure (reduces preload)
Indapamide	Indapamide stimulates the synthesis of prostaglandin E 2 in the endothelium, weakens the reaction of smooth muscles to pressor amines, prevents the entry of calcium ions into them through voltage-dependent L-type channels, exhibits the properties antiplatelet agent, causes regression of left ventricular hypertrophy.	Used for arterial hypertension. It only has a hypotensive effect, since 80% of the molecules accumulate in the arterial wall. Reduces blood pressure in 80% of patients resistant to inhibitor therapy angiotensin-converting enzyme. Moderate diuretic effect indapamide occurs by the end of the first week of course therapy and becomes maximum after 3 months.
Acetazolamide	Reduces the secretion of cerebrospinal fluid and intracranial pressure. Inhibits secretion intraocular fluid. Removes bicarbonates. Reduces HCl secretion Inhibits the activity of carbonic anhydrase of the kidneys, central nervous system and ciliary body, which disrupts the metabolic reabsorption of Na + and H + ions, increases diuresis. Promotes elimination K + , P 5+ , Ca 2+ development	Used for hydrocephalus and epilepsy. Used for glaucoma. Prescribed together with sodium bicarbonate. Control the release of HCl Edema associated with chronic cardiopulmonary failure; Emphysema; Metabolic alkalosis;
Spironolactone	It disrupts the flow of Na+ into the vascular wall. Reduces afterload on the heart. Strengthens processes biotransformation cardiac glycosides. Competitively blocks intracellular aldosterone receptors that promote the transfer of Na + across cell membranes, enhances its removal from the body and inhibits elimination of K + and Mg. 2 +	Used for hypertension. Used for angina pectoris. Used for prevention intoxication. Hypokalemia; Heart failure; Arterial hypertension (in combination with thiazides);

table 2

Indications for the use of diuretics.

Indications	Drug of choice
Edema in cardiovascular failure	Triampur, triamterene, spironolactone, furosemide
Edema of renal origin	Furosemide, hydrochlorothiazide
Acute pulmonary edema	Furosemide, beckons (for toxic pulmonary edema)
Brain swelling	Mannitol, furosemide
Ascites in liver cirrhosis	Hydrochlorothiazide, acetazolamide
Glaucoma	Hydrochlorothiazide, acetazolamide
Epilepsy	Hydrochlorothiazide, acetazolamide
Hypertonic disease	Hydrochlorothiazide, triampur, amiloride
Forced diuresis	Furosemide, mannitol, ethacrynic acid
Metabolic acidosis	Hydrochlorothiazide, sodium bicarbonate
Metabolic alkalosis	Diacarb, sodium chloride, potassium chloride
Inflammatory diseases urinary tract	Decoction of bearberry leaves, juniper berries, horsetail, knotweed

Side effects of diuretics are mainly associated with a direct effect on the electrolyte balance and acid-base balance of the body.

Table 3

Side effects of diuretics

Types of Adverse Reactions	Means that cause side effects	Corrective measures and warnings
Associated with electrolyte disturbances
Hypokalemia		Combination with potassium-sparing diuretics. Using a diet rich in potassium.
Hyperkalemia	Triampur, spironolactone	Potassium restrictions in the diet. The use of glucose with insulin, calcium gluconate.
Hyponatremia	Hydrochlorothiazide, furosemide	Applications of sodium chloride
Associated with acid-base imbalance
	Acetazolamide	Used together with sodium bicarbonate. Reducing the dose or discontinuing the drug.
	Hydrochlorothiazide, furosemide, ethacrynic acid.	Application of triampur, ammonium chloride, calcium chloride.
Other side effects
Provocation	Hydrochlorothiazide, furosemide, ethacrynic acid.	Avoid long-term use. Prescription of uricosuric drugs.
Hyperglycemia	Hydrochlorothiazide, furosemide	Avoid use in patients with diabetes.
	Furosemide, ethacrine	Avoid long-term use and combination with aminoglycosides antibiotics.
Azotemia	Triamterene, amiloride	Prescription of Lespenefril
Formation of phosphate and oxalate stones.	Furosemide, ethacrine	Simultaneous administration hydrochlorothiazide warns excretion of Ca 2+ in urine.

General principles for prescribing diuretics

Daily diuresis during treatment should not exceed 2-2.5 liters.

Rational choice taking into account:

- severity of edema syndrome

- hemodynamic imbalance

- state of initial electrolyte balance

- features of the pharmacological characteristics of the diuretic, its undesirable effects

- individual tolerance

Combining diuretics

In urgent cases - intravenous administration of strong and fast-acting diuretics

Monitoring and correction of electrolyte and acid-base balance

Diuretics

		Method of appointment
Hydrochlorothiazide (hypothiazide, dichlothiazide) Dichlothiazidum(B)	Tablets of 0.025 and 0.1 No. 20	Orally 0.025-0.05 in the morning before meals.
Chlorthalidone (oxodoline) Chlortalidonum (B)	Tablets 0.05 N.50	1-2 tablets orally in the morning before meals.
Furosemide (Lasix) Furosemidum (B)	Tablets 0.04 N.50 Ampoules 1% solution 2 ml N.10	Take 1 tablet orally in the morning before meals. Into a muscle, into a vein, 2-3 ml 1-2 times a day.
Spironolactone (veroshpiron) Spironolactonum (B)	Tablets 0.025	Orally, 1 tablet 2-4 times a day.
Indapamide (arifon) Indapamidum (B)	Dragee 0.0025	Take 1 tablet orally in the morning before meals.
	Bottles of 30.0	Dissolve the contents of the bottle in 5% glucose solution or water for injection and inject into a vein by drip. (in the form of 10-15-20% solution)

Antigout drugs

Gout is a disease caused by a disorder of purine metabolism and is manifested by a high concentration of uric acid in the blood serum (hyperuricemia). As a result of the deposition of crystals of uric acid salts (urates) in the synovial tissue of joints and cartilage, repeated episodes of acute arthritis occur. In addition, the formation of uric acid kidney stones is possible.

When pharmacotherapy of gout, it is necessary to eliminate the acute attack as quickly as possible, as well as prevent repeated exacerbations and the formation of urate crystals in the tissues and kidneys.

Remedies for relieving an acute attack of gout:

Non-steroidal anti-inflammatory drugs: colchicine, naproxen, indomethacin, diclofenac, etc.

Steroid anti-inflammatory drugs: prednisolone, methylprednisolone, etc.

Remedies for the treatment of gout:

Uricodepressive(inhibit xanthine oxidase => decreases uric acid synthesis) : allopurinol

Uricosuric(increasing the excretion of uric acid by reducing the reabsorption of uric acid in the renal tubules) : etamide, sulfinpyrazone.

Mixed type: freak.

The name of the product, its synonyms, storage conditions and order of dispensing from pharmacies.	Release form (composition), quantity of the drug in the package.	Method of appointment average therapeutic doses.
Cystenal Cystenalum (B)	10 ml bottles	Inside, 3-4 (up to 10) drops. 3 times a day (with sugar, before meals).
Aethamidum (B)	Tablets 0.35	Orally, 1 tablet 4 times a day.
	Powder (granules) in bottles of 100.0	Orally, 1 teaspoon in half a glass of water 3-4 times a day before meals.
Allopurinol Allopurinolum (B)	Tablets 0.1	Orally, 1 tablet 2-3 times a day after meals.

Drugs that affect the tone and contractile activity of the myometrium.

Classification of drugs affecting the myometrium.

Royal funds weaken or strengthen uterine contractions. They are used to maintain pregnancy, stimulate labor and stop uterine bleeding.

Diuretics are diuretics, they facilitate the removal of fluid from the body, from tissues and increase the amount of urine output. Depending on which part of the kidneys they affect most and on their chemical structure, they are divided into several classes.

It should be remembered that any medications should be taken only as prescribed by a doctor, including diuretics, only according to strict indications. Diuretics have a number of contraindications and a lot of side effects and are prescribed depending on the disease and the cause of edema (see,).

How to choose diuretic tablets

For various diseases and conditions, a specific class of diuretics is selected:

• Saluretics are diuretics, remove potassium and magnesium ions, causing a diuretic effect:
  • loop - furosemide, bumetanide, torasemide, lasix, ethacrynic acid
  • sulfonamides - chlorthalidone, clopamide (usually chlorthalidone, clopamide is used in combination with beta-blockers, with antihypertensive drugs), indapamide - an antihypertensive drug
  • thiazide - cyclomethiazide, hypothiazide
  • carbonic anhydrase inhibitors - acetazolamide, diacarb
• Potassium-sparing diuretics- work in the efferent tubule, preventing potassium loss - amiloride, spironolactone, triamterene, veroshpirone, eplerenone
• Osmotic diuretics prevents the reabsorption of fluid due to the difference in osmotic pressure in the tubules - mannitol, urea (intravenous administration).

Which ones do doctors prescribe when:

• Arterial hypertension (high blood pressure) - thiazides and indapamide
• Nephrotic syndrome and heart failure are loop diuretics. Against the background of heart failure, intense swelling of the legs - parenteral administration of furosemide or Lasix.
• Diabetes mellitus, metabolic disorders - indapamide
• Increased secretion of aldosterone by the adrenal glands - spironolactone
• Osteoporosis - thiazides

Based on their action, diuretics can be divided into:

By efficiency
Strong	Furosemide, Trifas, Uregit, Lasix
Average	Hypothiazide, Cyclomethiazide, Oxodoline, Hygroton
Weak	Veroshpiron, Triamterene, Diacarb
By duration of action
Work for a long time (up to 4 days)	Eplerenone, Veroshpiron, Chlorthalidone
Medium-long (up to 14 hours)	Diacarb, Clopamide, Triamterene, Hypothiazide, Indapamide
Short acting (up to 8 hours)	Manit, Furosemide, Lasix, Torasemide, Ethacrynic acid
According to the speed of onset of effect
Quick (in 30 minutes)	Furosemide, Torasemide, Ethacrynic acid, Triamterene
Medium (after 2 hours)	Diacarb, Amiloride
Slow (2 days)	Veroshpiron, Eplerenone

Loop diuretics

Loop diuretics increase the excretion of sodium by the kidneys, and, accordingly, water. They cause strong, rapidly occurring, but short-term diuresis (no more than 6 hours), so they are usually used for emergency care. In case of chronic heart failure with severe edema, their use in short courses is possible.

These diuretics are effective in renal dysfunction, unlike others. But since loop diuretics cause loss of magnesium and potassium in the body, this negatively affects the functioning of the heart.

Contraindications: with anuria, hypersensitivity, acute glomerulonephritis, obstruction of the urinary tract by stone (see), urethral stenosis, hyperuricemia, gout, acute, mitral or aortic stenosis, arterial hypotension, impaired water-electrolyte metabolism.

Side effects:, drop in pressure, arrhythmias, collapse, weakness, headache, drowsiness, hearing and vision impairment, nausea, vomiting, thirst, loss of appetite, exacerbation of pancreatitis, acute urinary retention, decreased potency, hematuria, interstitial nephritis, skin itching, fever, photosensitization, erythema, dermatitis, anaphylactic shock, leg muscle cramps, muscle weakness, etc.

Furosemide
Furosemide 40 mg. 50 pcs. 20-30 rub.	Lasix 40 mg. 45 pcs. 50 rub.
Torosemide
Trigrim 10 mg. 30 pcs 500 rub. 5 mg. 30 pcs 270 rub.	Diuver 10 mg 20 pcs. 450 rub., 5 mg 20 pcs. 320 rub.

Sulfonamide diuretics

These include Indapamide, a blood pressure lowering agent (diuretic, vasodilator), which is similar in pharmacological properties to thiazides. The therapeutic effect occurs after 1-2 weeks of use, the maximum is achieved after 2-3 months and lasts up to 2 months.

Contraindications: severe liver failure, hypersensitivity, children under 18 years of age, women during lactation, with lactose intolerance, with caution during pregnancy, with disorders of water and electrolyte metabolism, hyperuricemia, hyperparathyroidism.

Side effect: drop in blood pressure, palpitations, arrhythmia, ECG changes, cough, sinusitis, pharyngitis, dizziness, drowsiness, headache, nervousness, drowsiness, insomnia, muscle spasms, malaise, depression, irritability, anxiety, constipation or diarrhea, nausea, vomiting, dryness in the mouth, pancreatitis, nocturia, polyuria, urticaria, skin itching, etc.

Indapamide: Akuter-Sanovel, Arindal, Arifon, Indap, Indipam, Indiur, Ionic, Ypres-Long, Lorvas, Retapres, Tenzar, as well as:

Arifon 2.5 mg. 30 pcs. 450 rub.	Indap 2.5 mg. 30 pcs. 100 rub.	Acripamide 2.5 mg. 30 pcs. 50 rub.

Thiazide diuretics

The point of action of thiazide diuretics is the distal tubules of the kidney. It is based on the fact that the drugs inhibit the reabsorption of sodium ions, which are followed by water along the pressure gradient. As a result, sodium is excreted along with excess water.

As a rule, thiazide diuretics exhibit a moderate diuretic effect. Some drugs in this group also have the ability to dilate blood vessels.

• By reducing the swelling of the vascular wall, drugs from the thiazide diuretic group are widely used in long-term combination therapy of arterial hypertension.
• The ability to remove external and internal edema makes these drugs relevant in the treatment of heart failure.
• Also used for edema associated with nephrotic syndrome.

The drugs are quickly absorbed and begin to act half an hour to an hour after administration. Their duration of action is about 12 hours, which allows taking the drugs once a day as an antihypertensive agent and up to 2 times when eliminating edema of cardiac origin. The advantage of this type of diuretic is that they do not disturb the acid-base balance of the blood.

Features of taking thiazide diuretics:

• May affect potassium and magnesium levels (with long-term therapy)
• Increases uric acid levels (undesirable for gout)
• Increases sugar levels (undesirable for diabetes)

Thiazide preparations: Hygroton, Hypothiazide, Dichlorothiazide, Oxodolin, Cyclometazide.

Hypothiazide 25 mg. 20 pcs. 100 rub.	Hypothiazide 100 mg. 20 pcs. 120 rub.

Potassium-sparing diuretics

Like thiazide drugs, potassium-sparing diuretics are saluretics and work at the level of the distal tubules. The principle of operation is similar to thiazides (impaired sodium reabsorption) and its loss along with water (Amiloride, Triampur).

Spironolactone has the opposite effect of aldosterone (the adrenal hormone that retains sodium and water). However, the effect of potassium-sparing diuretics is weak and develops slowly (by 2-5 days from the start of therapy).

• As a result, potassium-sparing diuretics are not suitable for independent diuretic therapy and, as a rule, are prescribed as an additional diuretic, for example, in secondary hyperaldosteronism, heart failure resistant to basic therapy, nephrotic syndrome, cirrhosis of the liver.
• Also, this group becomes the drugs of choice in case of intolerance to drugs that wash out potassium in the treatment of heart diseases, for example, with edema syndrome.
• When combined with loop or thiazide diuretics, potassium-sparing drugs prevent significant losses of potassium in the urine.
• Primary hyperaldosteronism (adrenal tumor) also requires the prescription of these diuretics (veroshpiron). The drugs are suitable for patients with diabetes and gout.

Potassium-sparing agents: Spironolactone (Veroshpiron), Amiloride, Triamterene (Triampur).

Spironolactone		Eplerenone
Verospilactone 25 mg. 20 pcs. 70 rub.	Veroshpiron 25 mg. 20 pcs. 90 rub.	Espira, Inspra 25 mg. 30 pcs. 2600 rub.

Hydrochlorothiazide+Triamterene
Triampur compositum 50 pcs 310 rub.	Apo-Triazide 50 pcs. 200 rub.

Carbonic anhydrase inhibitors

This group of drugs includes Diacarb. Normally, the enzyme carbonic anhydrase promotes the formation of carbonic acid in the kidneys from water and carbon dioxide, which replenishes the alkaline reserve of the blood. By blocking the enzyme, Diacarb promotes the excretion of sodium in the urine, which draws water with it. At the same time, an increased amount of potassium is lost in the urine. Diacarb gives a weak effect that develops quite quickly (after an hour when taken in tablets, after half an hour when administered intravenously). Duration of action is about 10 hours (4 hours with parenteral administration).

The drug is used for:

• intracranial hypertension
• increased intraocular pressure
• in case of poisoning with salicylates and barbiturates to alkalize urine
• during treatment with cytostatics
• for gout

Herbal diuretics

Despite the fact that medicinal herbs are not synthetic drugs, but natural herbal teas that have a diuretic effect, they should also be treated as medicine. They also have contraindications and side effects (most often allergic reactions), and cannot be compared with medications in terms of effectiveness and speed of action. But in some cases, their effect is sufficient to remove excess fluid from the body (see.