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9

Diuretics

What will I learn?
In this section you will learn:
• Why diuretics should be used in heart failure
• How they improve symptoms and outcomes
• How to start and titrate the dose
• What the possible side effects are and what to do about them
Activation of the RAAS by the failing heart leads to fluid and salt retention
...

The diuresis caused by thiazide diuretics such as bendroflumethiazide
is usually fairly mild, whereas loop diuretics such as furosemide are more
powerful and will cause the body to swiftly excrete the excessive amounts
of fluid being retained
...
It is important to remember, then, that the action of diuretics
is a positive effect, rather than an annoying side effect
...

Another drug that has a powerful diuretic effect is metolazone
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Renal function, urea and electrolytes should also be closely observed
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Diuretics

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Metolazone is unusual in that it
has a strong diuretic effect despite being a thiazide diuretic
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How do diuretics improve symptoms and outcomes?
Loop diuretics will improve symptoms associated with fluid overload
within hours of being taken
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They are used purely to relieve symptoms and
thus improve quality of life
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When the patient needs more, he takes more; as symptoms improve, he
takes less and he may even be able to stop diuretic therapy for periods of
time (Table 1)
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Diuretic therapy − ESC guidelines

Initial diuretic treatment
Loop diuretics or thiazides
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Recheck every 5−7
days until potassium values are stable
GFR = glomerular filtration rate
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Pocket Guide to Chronic Heart Failure

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Side effects
Loop diuretics act on the Loop of Henle in the kidney and prevent reabsorption of water and salt
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Other side effects include gout, which
results from raised uric acid levels (hyperuricaemia) (Table 2, Fig
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Table 2
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5−1
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5

10

Hydrochlorothiazide

25

50−75

Metolazone

2
...
5

5

Potassiumsparing diuretics

+ACEI

−ACEI

+ACEI

Amiloride
Triamterene
S
 pironolactone

2
...
5−25

5
50
50

20
100
50

Hypokalaemia,
hypomagnesaemia,
hyponatraemia
Hyperuricaemia,
glucose intolerance
Acid−base disturbance

Thiazides

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Sites of reabsorption and secretion in the nephron of the
kidney
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indb 44

Pocket Guide to Chronic Heart Failure

16/9/08 11:10:05

Rosie presented with swollen feet
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A dose
of 40−80 mg is often used initially
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siumed
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htm
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For more information on the pharmacological aspects of diuretics go to
http://umed
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utah
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htm

What you need to know
Diuretics should be used in heart failure for symptomatic control
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c The dose should be started at a level appropriate to the severity of
symptoms and should be decreased as the symptoms improve – this
will ensure that symptoms are treated effectively
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These can be reduced by titrating the dose to the
appropriate level to avoid over-treatment
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What are the main sub-groups of diuretics?
2
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Which side effects would you monitor for and how would you do
this?

Diuretics

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