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PubMed1991

Chronopharmacology of the new uricosuric diuretic S-8666 in rats: (II). Examination in aged rats.

We have previously demonstrated a time-dependent variability in the diuretic effects of S-8666, a new loop diuretic with uricosuric activity, in young rats. The present study was undertaken to determine whether such a daily variation in the effects of the agent exists in aged rats. S-8666 (30 and 90 mg/kg) was orally given at 12:00 a.m. (day trial) or at 12:00 p.m. (night trial) in young (10-11 week old) and aged (23-24 month old) Wistar rats. Urine was collected for 8 hours after the agent; and urinary excretions of sodium, S-8666 and its active metabolite S-8680 were determined. Urinary excretions of volume and sodium following S-8666 at 12:00 a.m. were greater than those at 12:00 p.m. in the young and aged animals. Urinary excretions of S-8666 and S-8680 were also greater in the day trial compared to those in the night trial in both groups of rats. In the day and night trials, there were significant correlations between urinary S-8666 + S-8680 and the diuretic effects in both groups of rats. These findings indicate that the diuretic effects of S-8666 also vary with its time of dosing in aged rats. The time-dependent variations in urinary S-8666 and S-8680 might be involved in this phenomenon.

Aging↗
PubMed1991

ICI 181,037: a novel eukalemic diuretic with antiarrhythmic activity.

ICI 181,037, the most active compound from a series of 1,1-diarylcarbin-1-ol-2 amines, was evaluated for diuretic and cardiovascular activity. In saline-loaded rats, the magnitude of water diuresis and saluresis produced by ICI 181,037 (10 mg/kg, p.o.) was equal to that of hydrochlorothiazide. Water diuresis and saluresis produced by ICI 181,037 were enhanced with SKF 525A, ampicillin or neomycin plus lincomycin, suggesting that ICI 181,037 is an active diuretic. In conscious dogs, the saluretic activity of ICI d-181,037 (5 mg/kg, p.o.) was about 80% of the corresponding hydrochlorothiazide value, whereas the l-isomer demonstrated only minimum saluretic activity. In both rats and dogs, the concurrent kaliuresis after ICI 181,037 or its enantiomers was minimal as compared to hydrochlorothiazide. Following chronic dosing with diuretic doses, the basal levels of plasma potassium in dogs were not altered. In amphibian in vitro models for mimicking mammalian nephron, ICI 181,037 and its enantiomers demonstrated antinatriferic and antichloriferic activities, suggesting multiple renal sites of action for this agent. Racemic ICI 181,037 and its isomers reversed ouabain-induced arrhythmia in dogs and/or reduced the ouabain-induced mortality in mice after intravenous administration. It is concluded that ICI 181,037, particularly its d-isomer, is a novel eukalemic diuretic and possesses antiarrhythmic activity.

Acetamides↗
PubMed2003

The effects of the loop diuretics furosemide and torasemide on diuresis in dogs and cats.

Torasemide is a new loop diuretic that combines the effects of furosemide and spironolactone. There are no reports on the effects of torasemide in cats and dogs. This study compared the diuretic effects of furosemide and torasemide in cats and dogs. Cats with pressure overload cardiac hypertrophy were given oral placebo, torasemide 0.3 mg/kg, or furosemide 1 mg/kg or 3 mg/kg. Control and mitral regurgitation dogs were given oral placebo, torasemide 0.2 mg/kg, and furosemide 2 mg/kg for 7 days. Urine samples were obtained at baseline and 1, 2, 3, 4, 5, 6, 8, 12, and 24 hr after each drug dose. Urine volume and urine Na(+) and K(+) were measured. Both furosemide and torasemide increased urine volume 1 hr after administration. Furosemide caused a dose-dependent increase in urine volume that peaked at 2-3 hr in cats and dogs. The diuretic effect of furosemide disappeared 6 hr after administration, while that of torasemide peaked 2-4 hr after administration and persisted for 12 hr in cats and dogs. In MR dogs, torasemide for 7 days significantly decreased urine potassium excretion. Plasma aldosterone increased with torasemide, whereas there was no change with furosemide. In conclusion, about 1/10 concentration of torasemide was as potent as furosemide and had a longer diuretic effect in cats and dogs. These data suggest that torasemide is useful for treating congestive heart failure or edema in cats and dogs.

Animals↗
PubMed2003

Combined furosemide and human albumin treatment for diuretic-resistant edema.

OBJECTIVE: To evaluate the clinical usefulness of combined furosemide and human albumin for the treatment of diuretic-resistant edema in patients with nephrotic syndrome and cirrhosis. DATA SOURCES: Clinical literature was accessed through MEDLINE (1966-May 2002). Key search terms included furosemide, albumin, human albumin solution, nephrotic syndrome, and cirrhosis. DATA SYNTHESIS: Hypoalbuminemia, edema, and ascites are often manifestations of nephrotic syndrome and cirrhosis of the liver. Many patients with these conditions are resistant to the effects of diuretics. The combination of furosemide and human albumin solution is occasionally used in these patients. An evaluation of published studies focusing on combined furosemide and albumin in the management of nephrotic syndrome and cirrhosis was conducted. CONCLUSIONS: Published studies report conflicting results regarding the efficacy of combined furosemide and albumin. Although it is difficult to generate firm conclusions, it appears the combination may provide clinical benefits for select patients. Given these findings, we believe that the addition of albumin to enhance diuretic efficacy should be reserved for patients with recalcitrant edema or ascites in whom diuretic doses have been maximized and those with severe hypoalbuminemia.

Albumins↗
PubMed1997

Effect of diuretics on urinary oxalate, calcium, and sodium excretion in very low birth weight infants.

OBJECTIVE: To study the effect of diuretic drugs on urinary oxalate excretion in premature infants, and to examine the relationship between urinary calcium and sodium excretion in premature infants. METHODOLOGY: We measured urinary oxalate, calcium, and sodium excretion in 32 premature infants at approximately 34 weeks gestational age. Seven infants were receiving furosemide, 5 infants were receiving thiazide, 8 infants were receiving furosemide plus thiazide, and 12 infants who were not receiving diuretics served as controls. RESULTS: Urinary oxalate to creatinine ratios in infants receiving furosemide (0.48 +/- .26), thiazide (0.54 +/- .20), furosemide plus thiazide (0.44 +/- .19), and control infants (0.51 +/- .43) were similar by analysis of variance (ANOVA). Data expressed as oxalate concentration gave similar results. Urinary calcium to creatinine ratios in infants receiving furosemide (0.81 +/- .30), thiazide (0.54 +/- .25), furosemide plus thiazide (0.75 +/- .49), and control infants (0.37 +/- .25) were similar by ANOVA. The urinary calcium concentration in infants receiving furosemide plus thiazide (0.085 +/- 0.042 mg/mL) was different from control infants (0.044 +/- .023) by ANOVA and Student-Newman-Keuls test. Urinary calcium to creatinine ratio was correlated with sodium to creatinine ratio (r = .751). CONCLUSION: Urinary oxalate excretion in premature infants is not affected by diuretic drugs. Urinary sodium and calcium excretion are closely linked in sodium supplemented premature infants receiving diuretics. The calciuric effect of furosemide is not decreased by the addition of thiazide in premature infants receiving sodium supplements.

Analysis of Variance↗
PubMed2003

Diuretics: drugs of choice for the initial management of patients with hypertension.

The optimal first-line treatment of hypertension has been a contentious issue. Despite the probable advantage of diuretics, which was demonstrated in early clinical trials, concern about their metabolic effects meant that therapy was often commenced with drugs of other types. The results of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), which compared agents of three groups of new antihypertensive drugs with a diuretic, demonstrated the equivalence between these drugs and chlorthalidone (Tenoretic AstraZeneca) in the prevention of incident fatal coronary heart disease and nonfatal myocardial infarction. The diuretic was superior to other drugs in preventing some major secondary end-points, such as cerebrovascular disease and heart failure. These findings, together with other very practical reasons, such as easy administration, few side effects and low cost, demonstrate that diuretics are the first option for drug management of hypertension.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed2005

Should a diuretic always be the first choice in patients with essential hypertension? The case for no.

A more extensive use of diuretics as first-line drug for the treatment of hypertensive patients has been recommended on the basis of the results of the recent Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial, yet diuretics have numerous drawbacks that may limit their undisputed ability to lower BP. These include the stimulation of the renin-angiotensin-aldosterone system with the attending negative cardiovascular effects that ensue from this activation and several metabolic alterations, namely those in glucose, lipid, and potassium metabolism. Numerous mechanistic as well as interventional trials indicate that these limitations of diuretics can adversely affect the clinical outcome of patients and their compliance to treatment and consequently the cost of therapy. In addition, there are a number of clinical conditions in which the diuretics are admittedly contraindicated as first-line drugs. Thus, the emphasis should be on obtaining optimal BP control rather on the drug used to achieve it.

Cardiovascular Diseases↗
PubMed2001

Loop diuretic infusion increases thiazide-sensitive Na(+)/Cl(-)-cotransporter abundance: role of aldosterone.

Chronic infusion of loop diuretics into animals induces structural and functional changes in the distal nephron. These changes include increases in the activity of the thiazide-sensitive Na(+)/Cl(-)-cotransporter (NCC). The NCC was recently demonstrated to be an aldosterone-induced protein. These experiments were designed to test the hypotheses that chronic loop diuretic infusion, with replacement of NaCl losses, increases NCC protein abundance and that this effect results, in part, from stimulation by aldosterone. Sprague-Dawley rats received vehicle (group 1), furosemide (22 mg/100 g body wt per d) (group 2), or furosemide plus spironolactone (22 and 20 mg/100 g body wt per d, respectively) (group 3). Urine output was higher for groups 2 and 3 than for group 1 (151 +/- 32, 149 +/- 24, and 12 +/- 4 ml, respectively; P < 0.0001). Immunoblot analysis of NCC protein demonstrated that loop diuretics increased NCC protein abundance by nearly 100% (from 2562 +/- 30 to 5248 +/- 151 arbitrary units, P < 0.01). Spironolactone decreased NCC protein abundance by 66% (to 3532 +/- 113 units), compared with the furosemide-treated group (P < 0.005). Northern blot analysis of NCC mRNA demonstrated no significant effect of furosemide (NCC/glyceraldehyde-3-phosphate dehydrogenase ratios: group 1, 0.6 +/- 0.12; group 2, 0.5 +/- 0.05; P > 0.05, NS) These results indicate that increased NCC activity during chronic loop diuretic infusion is associated with increases in NCC protein abundance. A portion of the furosemide effect can be prevented by blockade of mineralocorticoid receptors.

Aldosterone↗
PubMed1997

Sudden cardiac death in patients with hypertension. An association with diuretics and beta-blockers?

The cornerstones of current antihypertensive treatment are diuretics and beta-blockers and the efficacy of these drugs in preventing cardiovascular disease is undisputed. This article focuses on the effect of these 2 drug classes on the incidence of sudden death. Numerous studies have shown that thiazide diuretics have a strong, dosage-dependent potassium-depleting effect, and it has been postulated that this may explain why the reduction in risk of coronary heart disease, observed in hypertension trials, was less pronounced than expected. In 7 trials that included sudden death as an end-point; a pooled risk-ratio of sudden death of 1.5 (95% confidence interval 1.1 to 2.0) was observed when non-potassium-sparing diuretics were compared with placebo. Two recent case-control studies have also strongly indicated that the use of thiazides increases the risk of sudden death. Evidence from trials using potassium-sparing diuretic combinations suggests that these may be better tolerated than thiazide monotherapy. Although it was suggested in the 2 recent case-control studies that recipients of beta-blockers are also at an increased risk of sudden death, further studies are required to confirm this finding, particularly since these drugs have several well-documented cardioprotective effects.

Adrenergic beta-Antagonists↗
PubMed2002

Severe heart failure in the elderly: potential benefits of high-dose and continuous infusion diuretics.

Heart failure (HF) is a growing problem among the elderly that results in significant morbidity and mortality. Congestive symptoms because of sodium and water retention are a major cause of impaired functional capacity and frequent hospitalisations. Patients with severe HF often develop resistance to traditional doses of diuretics. Subtherapeutic diuretic regimens may result in prolonged hospitalisation and thus increased costs. Numerous studies have shown that aggressive high-dose regimens of loop diuretics can be safely and effectively used in elderly patients with severe HF. Continuous intravenous infusions are a particularly effective method for delivering high daily doses of diuretics and rapidly removing large amounts of excess sodium and water. In our experience, continuous intravenous infusions are a well tolerated and effective treatment, which may shorten the duration of hospitalisation and in turn reduce the costs of treating elderly patients with HF.

Aged↗
PubMed1984

Intracellular magnesium loss after diuretic administration.

Diuretic agents influence the renal handling of magnesium, causing increased losses of the ion. Continuing magnesium losses may, in the long term, result in a magnesium deficiency. 296 patients with congestive heart failure or arterial hypertension receiving long term diuretic therapy were studied by skeletal muscle biopsies to assess their magnesium status. 65% of the congestive heart failure patients and 42% of the patients with arterial hypertension were found to have subnormal values for skeletal muscle magnesium. Studies with the potassium-sparing diuretics amiloride, spironolactone and triamterene demonstrate that these drugs significantly increase the muscle magnesium content in patients on long term diuretic treatment for congestive heart failure and/or arterial hypertension--in addition to their well known positive effect on potassium balance.

Diuretics↗
PubMed1984

Effects of diuretics on the renal handling of magnesium.

Diuretic-induced magnesium losses may contribute significantly to magnesium deficiency. Loop diuretics especially cause major losses of urinary magnesium. Our initial experiments in saline-loaded rats indicated that frusemide greatly increased magnesium excretion, while bendrofluazide caused no significant change and triamterene actually decreased magnesium excretion. Therefore, not all diuretics are magnesium-wasting. There is evidence that the potassium-sparing diuretic amiloride may also exert magnesium-sparing properties. In saline-loaded rats, the magnesium-sparing effect of amiloride was demonstrated when the drug was administered either alone or in combination with frusemide. Renal clearance studies in rats indicated that the magnesium-sparing effect of amiloride was a direct renal action and not secondary to possible extrarenal actions. A dose-response relationship has been established for the effect of amiloride in reducing fractional excretion of magnesium and potassium during frusemide diuresis in rats. Congestive heart failure patients being treated with frusemide were found to be both potassium- and magnesium-deficient, as indicated by reduced lymphocyte concentrations of potassium and magnesium. In these patients, amiloride reduced urinary magnesium and potassium, increased plasma magnesium and potassium, and also increased lymphocyte magnesium and potassium. The effects of amiloride most likely involve enhanced reabsorption of magnesium, but further studies are required to establish the precise mechanism(s) involved in the drug's magnesium-sparing properties.

Amiloride↗
PubMed1985

How dangerous are diuretics?

The proposal that thiazide diuretics may increase cardiovascular risk receives no support from recent data. Current evidence does not indicate that diuretic-induced hypokalaemia is associated with increased ventricular arrhythmias. This evidence includes continuous electrocardiographic monitoring--which is the most sensitive technique for quantitating cardiac arrhythmias. In contrast to earlier reports, more recent studies found no evidence for increased arrhythmias during the period of hypokalaemia, or for decreased arrhythmic activity after correction of hypokalaemia. Similarly, studies claiming increased sudden death in patients on diuretic treatment have not been substantiated by the results of other large-scale trials. Elevation of serum cholesterol concentrations with thiazide appears to be a short term phenomenon since most studies indicate the elevation reverts to baseline during long term treatment. Thiazide diuretics remain as one of our most effective antihypertensive agents. Fears of their increasing the incidence of ventricular arrhythmias due to hypokalaemia, or constituting a risk factor for atherosclerosis by elevating serum cholesterol concentrations, appear largely unsubstantiated.

Antihypertensive Agents↗
PubMed1988

Effects of diuretic drugs on the lipid profile.

Thiazide-type diuretic drugs modify the lipoprotein profile when used in the short term treatment of hypertension. Total cholesterol increases by 6 to 7% on average because of raised concentrations of low density or very low density lipoprotein cholesterol or both. High density lipoprotein cholesterol does not change. Spironolactone has a lesser effect on lipids than do thiazides. In contrast, the methylindoline compound, indapamide, a diuretic with vasodilator activity, has produced no adverse effects on lipids or lipoproteins. Long term data on thiazide monotherapy are sparse but suggest a persistence of the lipid effect for as long as 6 years of treatment. The clinical impact of these lipid changes is unclear. Although clinical trials have proved the benefit of lowering cholesterol on the incidence of coronary heart disease, the clinical significance of these diuretic-induced increases is unknown. A clinical trial will be required to resolve the issue by comparing antihypertensive drugs with and without adverse effects on the lipid profile. Because coronary heart disease is the most common complication of mild hypertension, and as diuretic-based regimens have not succeeded in curbing it, resolution of this concern is important.

Benzothiadiazines↗
PubMed1991

Low dose loop diuretics in essential hypertension. Experience with torasemide.

Diuretics belong to the class of antihypertensive drugs recommended for first-line therapy of essential hypertension. Although they are widely and effectively used for the treatment of hypertension, the question remains whether their possible negative influence on metabolic and electrolyte parameters could partly offset the benefit of blood pressure reduction with respect to reduction of coronary artery disease. Recently published data demonstrate that much lower doses of thiazides exert the same antihypertensive effect as the higher doses used in the past and even prescribed today. These lower doses produce relatively little change in biochemical parameters. Thus, the postulated risks can be avoided by using the lowest effective dose. Traditionally, loop diuretics of the furosemide (frusemide) type are rarely used as first-line antihypertensive agents. They seem to display less efficacy coupled with an intense diuresis when used in standard available doses. However, there is evidence that newly developed loop diuretics, in lower doses than used in congestive heart failure, are effective antihypertensive agents. For example, torasemide 2.5mg once daily, which does not exert a significant diuresis over 24 hours compared with placebo, lowers elevated blood pressure to a similar extent than thiazides or related compounds. This antihypertensive effect is accompanied by less, if any, changes in metabolic or electrolyte parameters compared with widely used standard diuretics such as hydrochlorothiazide, indapamide or chlorthalidone. The influence on serum potassium and magnesium is similar to or even less than fixed combinations of hydrochlorothiazide and triamterene or amiloride. Thus, low-dose torasemide constitutes an alternative to established thiazide antihypertensive therapy.

Diuretics↗
PubMed1994

Do non-potassium-sparing diuretics increase the risk of sudden cardiac death in hypertensive patients? Recent evidence.

Whether non-potassium-sparing diuretics (NPSD) increase the risk of sudden cardiac death in hypertensive patients has been vigorously debated. Diuretic-induced potassium or magnesium depletion leading to cardiac arrhythmias has been suggested as the underlying mechanism. A clear dose-response relationship between NPSD and the reduction in serum K+ exists. Data regarding serum Mg++ and intracellular K+ and Mg++ are too limited to allow conclusions. NPSD seem to increase the risk of ventricular arrhythmias among hypertensive patients with clinical evidence of heart disease, but the number of studies is small. The findings among patients without evidence of heart disease are less conclusive. The interpretation of the studies on electrolyte changes and arrhythmias following diuretic therapy is obscured by the fact that only a minority of studies included a randomly allocated placebo-treated control group. The large hypertension trials provide the strongest evidence that NPSD for hypertension may induce sudden death. Although blood pressure lowering may be expected to reduce the incidence of sudden cardiac death, the incidence in the NPSD group is similar to or even higher than that in the control group in 9 of 10 trials. We conclude that the beneficial effect of NPSD therapy for hypertension is partly offset by an excess risk of sudden death. Thus, alternative drugs, notably potassium-sparing diuretics or beta-blockers, could be preferred as antihypertensive drugs of first choice, although the efficacy of beta-blockers in older patients has recently been challenged.

Adult↗
PubMed1993

Cost-effectiveness of antihypertensive treatment: metoprolol versus thiazide diuretics.

The aim of the present analysis was to calculate the cost-effectiveness of metoprolol versus thiazide diuretics in middle-aged men with mild to moderate uncomplicated hypertension. The analysis was based on the Metoprolol Atherosclerosis Prevention in Hypertensives (MAPHY) study, a randomised trial which showed a significantly lower risk for coronary events in patients taking metoprolol than in patients on thiazide diuretics. The main analysis was based on Swedish costs, but the costs were also varied in a special sensitivity analysis. Metoprolol was shown to be cost-saving compared with thiazide diuretics when both direct and indirect costs of morbidity were included. When only direct costs were included, the cost per life-year gained was $US2400. The result of the present analysis suggests that metoprolol is to be preferred to thiazide diuretics from a cost-effectiveness standpoint in the treatment of mild to moderate hypertension in middle-aged men. These findings regarding cost-effectiveness should, however, not be extrapolated to patient groups not included in the MAPHY trial.

Benzothiadiazines↗
PubMed1981

Increased extravasation and lymphatic return rate of albumin during diuretic treatment of ascites in patients with liver cirrhosis.

During steady state the overall lymphatic return rate of albumin equals the transvascular escape rate of albumin [TERalb, i.e. the fraction of intravascular mass of albumin (IVMalb) passing to the extravascular space per unit time] provided local back-transport is negligible, as previously substantiated in patients with cirrhosis. In nine untreated patients with cirrhotic ascites, TERalb (as determined from the disappearance of intravenously injected radiodinated serum albumin) was on the average 8.5% IVMalb X h-1 (range 4.6-12.7). This value is higher than that of normals (mean 5.9% IVMalb X h-1, range 4.3-7.4, P less than 0.05, one-sided tests). During diuretic treatment TERalb increased to a mean of 13.0% IVMalb.h-1 (range 9.2-22.2), which is significantly higher compared to the untreated state (P less than 0.05) and compared to normals (P less than 0.01). In the untreated condition IVMalb was mean 1.24 mmol (range 0.96-1.64), and this value increased by 20% (P less than 0.01) to an average of 1.49 mmol (range 1.36-1.79) during diuretic treatment. The average increase in IVMalb (0.25 mmol) corresponded to 45% of the intraperitoneal mass of albumin in the untreated state (mean 0.59 mmol), indicating a net transport of albumin from the peritoneal cavity to the plasma during diuretic treatment. The results suggest an increased lymphatic drainage of albumin during diuretic treatment, which may play a role in amelioration of cirrhotic ascites.

Adult↗