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Diuretics
Acetazolamide (Diamox ® )
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Class: Carbonic anhydrase inhibitor Treatment of glaucoma (chronic simple open-angle, secondary glaucoma, preoperatively in acute angle-closure); drug-induced edema or edema due to congestive heart failure (adjunctive therapy); centrencephalic epilepsies (immediate release dosage form); prevention or amelioration of symptoms associated with acute mountain sickness Mechanism of Action Reversible inhibition of the enzyme carbonic anhydrase resulting in reduction of hydrogen ion secretion at renal tubule and an increased renal excretion of sodium, potassium, bicarbonate, and water to decrease production of aqueous humor; also inhibits carbonic anhydrase in central nervous system to retard abnormal and excessive discharge from CNS neurons Dosing (adults): Note: I.M. administration is not recommended because of pain secondary to the alkaline pH Glaucoma: Chronic simple (open-angle): Oral: 250 mg 1-4 times/day or 500 mg sustained release capsule twice daily Secondary, acute (closed-angle): I.V.: 250-500 mg, may repeat in 2-4 hours to a maximum of 1 g/day Edema: Oral, I.V.: 250-375 mg once daily Epilepsy: Oral: 8-30 mg/kg/day in 1-4 divided doses; sustained release capsule is not recommended for treatment of epilepsy Mountain sickness: Oral: 250 mg every 8-12 hours (or 500 mg extended release capsules every 12-24 hours) Therapy should begin 24-48 hours before and continue during ascent and for at least 48 hours after arrival at the high altitude Urine alkalinization (unlabeled use): Oral: 5 mg/kg/dose repeated 2-3 times over 24 hours Respiratory stimulant in COPD (unlabeled use): Oral, I.V.: 250 mg twice daily Elderly: Oral: Initial: 250 mg twice daily; use lowest effective dose Dosing adjustment in renal impairment: Clcr 10-50 mL/minute: Administer every 12 hours Clcr<10 mL/minute: Avoid use (ineffective) Hemodialysis: Moderately dialyzable (20% to 50%) Peritoneal dialysis: Supplemental dose is not necessary Administration Oral: May cause an alteration in taste, especially carbonated beverages; short-acting tablets may be crushed and suspended in cherry or chocolate syrup to disguise the bitter taste of the drug, do not use fruit juices, alternatively submerge tablet in 10 mL of hot water and add 10 mL honey or syrup [Supplied:: 125, 250 mg tablet. 500mg SR capsule. 500mg powder for injection.] |
Amiloride (Midamor ® )
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Class: Potassium sparing Diuresis: Start 5 mg po qd. Maintenance: 5-20 mg po qd. Maximum: 20mg/day. [Supplied: 5 mg tab] |
Amiloride and HCTZ (Moduretic ®)
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Class: Combination Potassium sparing and Thiazide Adult (usual) - Diuresis: 1 tab orally daily - may increase to 2 tabs orally daily. [Supplied: 5mg amiloride/50mg(hctz) tablet] |
Bendroflumethiazide (Naturetin ® )
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Class: Thiazide Adult (usual) Edema: initial, up to 20 mg po daily (divided once or twice daily). Maint: 2.5-5 mg po qd. Hypertension: initial, 5 to 20 mg orally daily (divided once or twice daily). Maint: 2.5-15 mg orally qd. Avoid use in patients with SCR >2.5 mg/dl. [Supplied: 2.5, 5, 10 mg tablet] |
Bumetanide (Bumex ® )
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Class: Loop Diuretic Management of edema secondary to congestive heart failure or hepatic or renal disease including nephrotic syndrome; may be used alone or in combination with antihypertensives in the treatment of hypertension; can be used in furosemide-allergic patients Mechanism of Action Inhibits reabsorption of sodium and chloride in the ascending loop of Henle and proximal renal tubule, interfering with the chloride-binding cotransport system, thus causing increased excretion of water, sodium, chloride, magnesium, phosphate and calcium; it does not appear to act on the distal tubule Dosing (adults): Oral, I.M., I.V.: Edema: Oral: 0.5-2 mg/dose (maximum dose: 10 mg/day) 1-2 times/day. I.M., I.V.: 0.5-1 mg/dose; may repeat in 2-3 hours for up to 2 doses if needed (maximum dose: 10 mg/day) . Continuous I.V. infusion: 0.9 to 1 mg/hour. Hypertension: Oral: 0.5 mg daily (maximum dose: 5 mg/day); usual dosage range (JNC 7): 0.5-2 mg/day in 2 divided doses Administration Administer I.V. slowly, over 1-2 minutes; an alternate-day schedule or a 3-4 daily dosing regimen with rest periods of 1-2 days in between may be the most tolerable and effective regimen for the continued control of edema; reserve I.V. administration for those unable to take oral medications Supplied Injection, solution: 0.25 mg/mL (2 mL, 4 mL, 10 mL) [contains benzyl alcohol] Tablet (Bumex®): 0.5 mg, 1 mg, 2 mg |
Chlorothiazide (Diuril ® )
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Class: Thiazide Mechanism of Action Inhibits sodium reabsorption in the distal tubules causing increased excretion of sodium and water as well as potassium and hydrogen ions, magnesium, phosphate, calcium Dosing (adults): Hypertension: Oral: 500 mg to 2 g/day divided in 1-2 doses (manufacturer labeling); doses of 125-500 mg/day have also been recommended Edema: Oral, I.V.: 500 mg to 1 g once or twice daily. Intermittent treatment (ie, therapy on alternate days) may be appropriate for some patients. Elderly: Oral: 500 mg once daily or 1 g 3 times/week Administration Do not administer injection via I.M. or SubQ route. Administer I.V. </= 0.5 g over 5 minutes. Supplied Injection, powder for reconstitution, as sodium: 500 mg Suspension, oral: 250 mg/5 mL (237 mL) [contains alcohol 0.5% and benzoic acid] Tablet: 250 mg, 500 mg |
Chlorthalidone (Hygroton ® )
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Class: Thiazide Management of mild to moderate hypertension when used alone or in combination with other agents; treatment of edema associated with congestive heart failure or nephrotic syndrome. Recent studies have found chlorthalidone effective in the treatment of isolated systolic hypertension in the elderly. Mechanism of Action Sulfonamide-derived diuretic that inhibits sodium and chloride reabsorption in the cortical-diluting segment of the ascending loop of Henle Dosing (adults) Oral: 25-100 mg/day or 100 mg 3 times/week; usual dosage range (JNC 7): 12.5-25 mg/day Elderly: Initial: 12.5-25 mg/day or every other day; there is little advantage to using doses >25 mg/day Dosage adjustment in renal impairment: Clcr<10 mL/minute: Administer every 48 hours Monitoring Parameters Assess weight, I & O records daily to determine fluid loss; blood pressure, serum electrolytes, renal function Supplied Tablet: 25 mg, 50 mg, 100 mg |
Dichlorphenamide ( Daranide ®)
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Class: Carbonic anhydrase inhibitor Adults: Oral: 100-200 mg to start followed by 100 mg every 12 hours until desired response is obtained; maintenance dose: 25-50 mg 1-3 times per day. [Supplied: 50 mg tablet] |
Eplerenone (Inspra ®)
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Class: Potassium sparing Treatment of hypertension (may be used alone or in combination with other antihypertensive agents); treatment of CHF following acute MI Mechanism of Action Aldosterone increases blood pressure primarily by inducing sodium reabsorption. Eplerenone reduces blood pressure by blocking aldosterone binding at mineralocorticoid receptors found in the kidney, heart, blood vessels and brain. Dosing (adults) Oral: Hypertension: Initial: 50 mg once daily; may increase to 50 mg twice daily if response is not adequate; may take up to 4 weeks for full therapeutic response. Doses >100 mg/day are associated with increased risk of hyperkalemia and no greater therapeutic effect. Concurrent use with moderate CYP3A4 inhibitors: Initial: 25 mg once daily Congestive heart failure (post-MI): Initial: 25 mg once daily; dosage goal: titrate to 50 mg once daily within 4 weeks, as tolerated Dosage adjustment per serum potassium concentrations for CHF: <5.0 mEq/L: Increase dose from 25 mg every other day to 25 mg daily or Increase dose from 25 mg daily to 50 mg daily 5.0-5.4 mEq/L: No adjustment needed 5.5-5.9 mEq/L: Decrease dose from 50 mg daily to 25 mg daily or Decrease dose from 25 mg daily to 25 mg every other day or Decrease does from 25 mg every other day to withhold medication >/= 6.0 mEq/L: Withhold medication until potassium <5.5 mEq/L, then restart at 25 mg every other day Dosage adjustment in renal impairment: Patients with hypertension with Clcr<50 mL/minute or serum creatinine >2.0 mg/dL in males or >1.8 mg/dL in females: Use is contraindicated; risk of hyperkalemia increases with declining renal function Patients with CHF post-MI: Use with caution Supplied Tablet [film coated]: 25 mg, 50 mg |
Ethacrynic acid (Edecrin ®)
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Class: Loop Diuretic SODIUM EDECRIN should not be given SC or IM because of local pain and irritation. Edema (adult): Oral: 50-100 mg/day in 1-2 divided doses; may increase in increments of 25-50 mg at intervals of several days to a maximum of 400 mg/24 hours. (ELDERLY — Oral: Initial: 25-50 mg/day.) IV: Usual: 50mg x 1 (0.5-1 mg/kg/dose). Maximum: 100 mg/dose. Usually only one dose has been necessary; occasionally a second dose at a new injection site, to avoid possible thrombophlebitis, may be required. A single intravenous dose not exceeding 100 mg has been used in critical situations. Preparation: Dilute in D5W or NS (1 mg/mL) and infuse over several minutes. [Supplied: 50 MG powder for inj. 25, 50mg tablet] |
Furosemide (Lasix ® )
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Class: Loop Diuretic Dosing (adults) Edema: initial: 20-40 mg IV/IM over 1-2 min. May repeat in 1 to 2 hours or may be increased by 20 mg until desired response. This individually determined dose may be given once or twice daily. Edema (oral): initial: 20-80 mg po qd - may repeat in 6-8 hrs. Maximum: 600 mg/day. HTN: initial: 80 mg po daily (divided twice daily). CHF: 250 to 4000 mg daily (IV or PO) Acute pulmonary edema: usual dose - 40 mg IV over 1-2 minutes. If not adequate, may increase dose to 80 mg. Continuous I.V. infusion: Initial IV bolus dose of 0.1 mg/kg followed by continuous I.V. infusion doses of 0.1 mg/kg/hour doubled q2h to a maximum of 0.4 mg/kg/hour if urine output is <1 ml/kg/hour. Other studies have used a rate of 4 mg/minute as a continuous IV infusion. Elderly: Oral, IM, IV: Initial: 20 mg/day; increase slowly to desired response. Refractory heart failure: Oral, IV: Doses up to 8 g/day have been used. Acute renal failure: High doses (up to 1-3 g/day - oral/IV) have been used to initiate desired response. Avoid use in oliguric states. Administration: IV injections should be given slowly over 1-2 minutes. Maximum rate of administration for IVPB or infusion: 4 mg/minute. Replace parenteral therapy with oral therapy as soon as possible. [Supplied 10 mg/ml, 40 mg/5 ml oral soln. 10 mg/ml soln for inj. 20,40, 50, 80mg tablet] |
Hydrochlorothiazide (Esidrix ®, HydroDiuril ®,
Microzide™)
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Class: Thiazide Dosing (adults) Edema: 25-100 mg po daily in single or divided doses. Hypertension (HTN): initial, 12.5-25 mg po once daily. Titration: allow 2-3 weeks to achieve optimum antihypertensive effect. Usual maintenance dose: 12.5 - 50mg/day. Maximum 50mg/day. Renal Dosing: GFR less than 15-25 mL/min, use not recommended. Patients with edema may respond to intermittent therapy (ie, administer on alternate days or 3-5 days / week). [Supplied: 25, 50, 100mg tablet. 12.5 mg capsule. 50mg/5 ml solution] |
HCTZ
/Triampterene (Dyazide ®, Maxzide ®)
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Class: Combination Potassium sparing and Thiazide Dosing (adults) HTN: initial, 1 tab or capsule (25 mg hydrochlorothiazide/37.5 mg triamterene) po qd. Allow 2-3 weeks to achieve optimum antihypertensive effect. May increase to maximum dose of 50/75 mg po qd (higher doses increase the risk of electrolyte imbalance and renal dysfunction). [Supplied 25 mg-37.5 mg capsule/tablet. 50 mg-75 mg tablet]. |
Hydroflumethiazide ( Diucardin ®)
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Class: Thiazide Dosing (adults) Edema: usual - 50 to 100 mg daily initially. Doses of 25 or 200 mg daily are used for maintenance therapy. HTN: usual adult dose - 12.5 to 50 mg daily. [Supplied: 50mg tablet] |
Indapamide (Lozol ® )
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Class: Thiazide Management of mild to moderate hypertension; treatment of edema in congestive heart failure and nephrotic syndrome Mechanism of Action Diuretic effect is localized at the proximal segment of the distal tubule of the nephron; it does not appear to have significant effect on glomerular filtration rate nor renal blood flow; like other diuretics, it enhances sodium, chloride, and water excretion by interfering with the transport of sodium ions across the renal tubular epithelium Adults: Oral: Edema: 2.5-5 mg/day. Note: There is little therapeutic benefit to increasing the dose >5 mg/day; there is, however, an increased risk of electrolyte disturbances Hypertension: 1.25 mg in the morning, may increase to 5 mg/day by increments of 1.25-2.5 mg; consider adding another antihypertensive and decreasing the dose if response is not adequate [Supplied 1.25, 2.5 mg tablet] |
Methazolamide (Neptazane ®)
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Class: Carbonic anhydrase inhibitor Adjunctive treatment of open-angle or secondary glaucoma; short-term therapy of narrow-angle glaucoma when delay of surgery is desired Mechanism of Action Noncompetitive inhibition of the enzyme carbonic anhydrase; thought that carbonic anhydrase is located at the luminal border of cells of the proximal tubule. When the enzyme is inhibited, there is an increase in urine volume and a change to an alkaline pH with a subsequent decrease in the excretion of titratable acid and ammonia. Dosage - Adults: Oral: 50-100 mg 2-3 times/day Glaucoma: 50-100 mg po bid - tid. Altitude sickness: 150-200 mg po daily. [Supplied: 25, 50 mg tablet] |
Methyclothiazide (Enduron ® )
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Class: Thiazide Edema: Initially: 2.5mg po qd. Range: 2.5-10 mg po qd. Hypertension: 2.5-5 mg po qd. [Supplied: 2.5, 5mg tablet] |
Metolazone (Zaroxolyn ®, Mykrox ®)
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Class: Thiazide Management of mild to moderate hypertension; treatment of edema in congestive heart failure and nephrotic syndrome, impaired renal function Mechanism of Action Inhibits sodium reabsorption in the distal tubules causing increased excretion of sodium and water, as well as, potassium and hydrogen ions Adults: Oral: Edema: 5-20 mg/dose every 24 hours Hypertension (Zaroxolyn®): 2.5 to 5 mg/dose every 24 hours Hypertension (Mykrox®): 0.5 mg/day; if response is not adequate, increase dose to maximum of 1 mg/day Administration May be taken with food or milk. Take early in day to avoid nocturia. Take the last dose of multiple doses no later than 6 PM unless instructed otherwise. [Supplied: Mykrox® 0.5 mg tablet. Zaroxolyn®: 2.5, 5, 10mg tablet] |
Polythiazide (Renese ®)
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Class: Thiazide Edema (Adult): 1-4 mg po qd. HTN: 2-4 mg po qd. [Supplied: 1, 2, 4 mg tablet] |
Spironolactone (Aldactone ® )
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Class: Potassium sparing Management of edema associated with excessive aldosterone excretion; hypertension; primary hyperaldosteronism; hypokalemia; treatment of hirsutism; cirrhosis of liver accompanied by edema or ascites Mechanism of Action Competes with aldosterone for receptor sites in the distal renal tubules, increasing sodium chloride and water excretion while conserving potassium and hydrogen ions; may block the effect of aldosterone on arteriolar smooth muscle as well Adults: Oral: To reduce delay in onset of effect, a loading dose of 2 or 3 times the daily dose may be administered on the first day of therapy. Edema, hypokalemia: 25-200 mg/day in 1-2 divided doses Hypertension (JNC 7): 25-50 mg/day in 1-2 divided doses Diagnosis of primary aldosteronism: 100-400 mg/day in 1-2 divided doses Acne in women (unlabeled use): 25-200 mg once daily Hirsutism in women (unlabeled use): 50-200 mg/day in 1-2 divided doses CHF, severe (with ACE inhibitor and a loop diuretic ± digoxin): 25 mg/day, increased or reduced depending on individual response and evidence of hyperkalemia Elderly: Initial: 25-50 mg/day in 1-2 divided doses, increasing by 25-50 mg every 5 days as needed. Dosing interval in renal impairment: Clcr 10-50 mL/minute: Administer every 12-24 hours. Clcr<10 mL/minute: Avoid use. Supplied Tablet: 25 mg, 50 mg, 100 mg |
Spironolactone and HCTZ (Aldactazide ®)
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Class: Combination Potassium sparing and Thiazide Adults: (25/25mg tablet): 0.5 to 8 tablets qd. (50/50 mg tablet): 0.5 to 4 tablets qd in 1-2 doses [Supplied: 25/25mg and 50/50mg tablets]. |
Torsemide (Demadex ® )
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Class: Loop Diuretic Edema (CHF): initial: 10-20 mg po or IV qd. Maintenance: may increase by doubling the dose. Maximum: 200 mg po or IV qd. Edema (liver disease): initial: 5-10 mg po or IV qd along with an aldosterone antagonist or potassium-sparing diuretic. Edema (renal failure): initial 20 mg po or IV qd. Maintenance: may increase by doubling the dose. Maximum: 200 mg po or IV qd. (HTN): initial 5 mg po qd. Allow 4-6wk to achieve optimum antihypertensive effect. May increase to 10 mg po qd. [Supplied: 10 mg/ml injection. 5, 10, 20 , 100mg tablet] |
Trichlormethiazide (Naqua ®)
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Class: Thiazide HTN/Edema: Initially - 2 mg po qd. Usual Maint: 2-4 mg po qd. [Supplied: 4 mg tablet] |
Triamterene (Dyrenium ®)
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Class: Potassium sparing Alone or in combination with other diuretics in treatment of edema and hypertension; decreases potassium excretion caused by kaliuretic diuretics Adults: Oral: 100-300 mg/day in 1-2 divided doses; maximum dose: 300 mg/day; usual dosage range (JNC 7): 50-100 mg/day Dosing comments in renal impairment: Clcr<10 mL/minute: Avoid use. Dosing adjustment in hepatic impairment: Dose reduction is recommended in patients with cirrhosis. [Supplied: 50, 100mg capsule]. |
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