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CLINICAL REVIEW

Diuretics: how they work,


cautions and contraindications
Health professionals have an important role to play in promoting adherence and
ensuring that quality of life is not compromised for patients taking diuretics, which
can reduce fluid reabsorption in the kidneys, as Gerri Kaufman explains

D
iuretics are substances that increase the Loop diuretics
secretion of water from the body through Loop diuretics, which include furosemide and bumetanide
their action on the kidney (Kaufman, 2013). are the most powerful diuretics (Khatib, 2011). They are
Diuretics are prescribed to manage conditions preferred over others because they produce a strong diure-
that are associated with the retention of excessive sis and maintain their diuretic effect in renal impairment
amounts of fluid such as hypertension and heart failure (Khatib, 20011).
(Harvey and Jordan, 2010). Diuretics can be divided Loop diuretic are so called because they act in a part of the
into three classes: loop diuretics, thiazide diuretics and nephron known as the ascending limb of the loop of Henle
potassium-sparing diuretics (Bennett, 2008) (Box1). (Greenstein and Gould, 2009). Loop diuretics are responsible
Diuretics are widely prescribed and when used for blocking the reabsorption of 2030% of water and
appropriately, are considered efficacious, cost effective electrolytes from the urine back into the circulation (Harvey
and generally well tolerated (Bennett, 2008). However, and Jordan, 2010). These drugs are therefore important in
diuretics are overprescribed in older people who are par- the management of the fluid retention associated with heart
ticularly susceptible to their side effects, which include failure that results in ankle oedema, pulmonary oedema
electrolyte disturbances (especially hypokalaemialow and breathlessness (Khatib, 2011). The loop diuretics work
serum potassium that can have significant consequenc- by removing excess fluid, which in turn, relieves oedema,
es such as abnormal heart rhythms and cardiac arrest), congestion and breathlessness. Furosemide and bumetanide
dehydration and hypotension (low blood pressure, which act within 1 hour of oral administration and diuresis is
can cause falls in older people) (Kaufman, 2013). Elec- complete within 6 hours (Joint Formulary Committee,
trolytes include substances such as sodium, potassium, 2013). This means that, if required, they can be given
hydrogen and magnesium. They need to be maintained twice daily without causing interference with sleep (Joint
at appropriate levels within the body. Diuretics can alter Formulary Committee, 2013).
their balance within the body.
This article will explore the different classes of Thiazides and thiazide-like diuretics.
diuretics and discuss the ways in which they affect the The thiazide diuretics, which include bendroflumethiazide
body. The cautions and contraindications of diuretics and indapamide, act in a part of the kidney known as the
will be noted and the side effects considered. Finally, distal convoluted tubule and prevent the reabsorption of of
practical issues in relation to the use of diuretics will be up to 10% of water and electrolytes water and electrolytes
addressed. (Harvey and Jordan, 2010). Therefore, a smaller diuresis
is usually associated with the thiazides compared to the
Indications for use and loop diuretics (Harvey and Jordan, 2010). The thiazide
mechanism of action diuretics act within 12hours of administration, and most
Loop, thiazide and potassium-sparing diuretics increase have a duration of action of 1224hours (Joint Formulary
the secretion of water from the body by inhibiting the
normal reabsorption of electrolytes, especially sodium
from the kidney back into the circulation. This leads to
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the retention of electrolytes and water, produces a larger Gerri Kaufman Senior Lecturer, Department of Health
volume of urine for excretion and causes a reduction in Sciences, University of York
the circulating blood volume (Simonsen et al, 2006). gerri.kaufman@york.ac.uk
The different classes of diuretics have a particular site
of action within the kidney (Harvey and Jordan, 2010).

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CLINICAL REVIEW

Distal convoluted tubule Box 1. Examples of diuretic drugs


Loop diuretics
Thiazides and thiazide-like
diuretics Furosemide
Bumetanide
Torasemide

Thiazide diuretics
Bendroflumethiazide
Metolozone
Chlortalidone
Indapamide

Potassium sparing diuretics


Loop diuretics Spironolactone (Aldosterone antagonist)
Eplerenone (Aldosterone antagonist)
Potassium-sparing diuretics Amiloride
Triamterene
From: Bennett, 2008; Kaufman, 2013.
Loop of Henl Collecting duct

Figure 1. Different diuretic actions


Potassium-sparing diuretics
Committee, 2013). They are normally administered early Potassium-sparing diuretics act on the collecting tubules
in the day so that the diuresis does not interfere with sleep of the kidney and block the loss of potassium. They
(Joint Formulary Committee, 2013). Thiazide diuretics can include two main classes of weak diuretics that are rarely
be used in patients with mild heart failure (Khatib, 2011) given alone. However, they can be administered alongside
and good renal function (Joint Formulary Committee, loop and thiazide diuretics to improve the therapeutic
2013). They are, however, ineffective in patients with renal response (Bennett, 2008). The first group of potassium-
impairment (Joint Formulary Committee, 2013). In patients sparing diuretics comprise the aldosterone antagonists
with heart failure, where diuresis with a single diuretic is spironolactone and eplerenone. Rather than directly
insufficient, a combination of a loop diuretic and a thiazide affecting sodium transport, these drugs inhibit the action of
may be tried (Joint Formulary Committee, 2013). This may aldosterone, which is a hormone that increases the secretion
be particularly useful in resistant chronic heart failure of potassium and reabsorption of sodium and water
as loop diuretics and the thiazides can have a synergistic (Hennefer, 2010). By inhibiting the action of aldosterone,
effect (Bennett, 2008). However, care must be taken when these drugs increase the excretion of sodium and water
combining both types of diuretics because they may induce but at the same time spare the excretion of too much
a significant diuresis, which puts the patient at risk of potassium. This is important to prevent low potassium levels
hypotension and dehydration (Bennett, 2008). (hypokalaemia), which can be dangerous (Hennefer, 2010).
Thiazide diuretics also have a place in the management These drugs have a fairly slow action as it can take
of hypertension (high blood pressure) (National Institute for 23 days for an effect to be observed. However, their ac-
Health and Care Excellence (NICE), 2011). Hypertension tion can then last for a further 23days (Bennett, 2008).
is one of the most preventable causes of heart disease and The second group of potassium-sparing diuretics include
stroke in the UK (Linden, 2011). Diuretics reduce systolic amiloride and triamterene. Of the two, amiloride is slower
and diastolic blood pressure by increasing the loss of sodium acting, and it can take around 6hours for the effects to oc-
and water (Bennett, 2008). This reduces the volume of cur. However, once the effects occur, they can persist for
fluid in the circulation (Harvey and Jordan, 2010) and up to 24 hours. Triamterene has an effect 2 hours after
lowers blood pressure. The use of a thiazide diuretic is administration and the effects can persist for 1216 hours
recommended in the NICE (2011) stepped approach to the (Bennett, 2008).
clinical management of primary hypertension in adults.
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Bennett (2008) suggests that, for most patients with normal Cautions, contraindications
renal function, thiazides offer better control over blood and side effects
pressure compared to loop diuretics. However, according Diuretics should be administered with caution and doses
to NICE (2011) chlortalidone and indapamide are the adjusted according to patient monitoring (Harvey and
preferred diuretics in the management of hypertension. Jordan, 2010). Older people are particularly susceptible to

84 NRC | February 2014, vol 16, no 2


CLINICAL REVIEW

Box 2. Cautions and contraindications of diuretics


Class of diuretics Cautions and contraindications
Loop diuretics Hypovalaemia and hypotension should be corrected before starting treatment with
loop diuretics
Electrolytes should be monitored during treatment
Loop diuretics can exacerbate diabetes and gout
Urinary retention can occur if there is an enlarged prostate
Loop diuretics should be avoided in severe hypokalaemia (hypokalaemia (low blood potassiu)
induced by loop diuretics can precipitate hepatic encephalopathy (confusion)and coma), severe
hyponatraemia (low blood sodium), anuria (lack of urine production), comatose and precomatose
states associated with liver cirrhosis (scarring), renal failure due to nephrotoxic (medicines harmful
to the kidney) or hepatotoxic drugs (medicines harmful to the liver) and severe liver disease
High doses or rapid intravenous administration can cause tinnitus and deafness
High dose bumetanide can cause musculoskeletal pain
In pregnancy: furosemide and bumetanide should not be used to treat hypertension
Thiazide diuretics Thiazide diuretics can exacerbate diabetes and gout and systemic lupus erythematous (a complex
condition that is caused by problems with the immune system resulting in fatigue, skin rash and
painful and swollen joints)
Thiazide diuretics should be used with caution in nephrotic syndrome and mild to moderate
hepatic impairment
Electrolytes should be monitored with the administration of high doses, long-term use and in
renal impairment
Thiazides should not be used to treat hypertension in pregnancy
Potassium-sparing Potassium supplements must not be given with potassium-sparing diuretics
diuretics Potassium-sparing diuretics can cause hypokalaemia if administered with an angiotensin-
converting-enzyme (ACE) inhibitor or an angiotensin 2 receptor antagonist
Potassium-sparing diuretics should be avoided in hyperkalaemia, anuria, Addisons disease (a
disorder of the adrenal glands) and severe renal impairment
When prescribed for individuals with renal impairment, the plasma-potassium concentration
should be monitored
Not recommended in pregnancy or breastfeeding
From: Joint Formulary Committee, 2013.

the side effects of diuretics and should be prescribed lower be given when administering diuretics to older people, as
doses initially. The dose can then be adjusted according hypotension can cause falls (Hennefer, 2010). Older people
to renal function (Joint Formulary Committee, 2013). are more susceptible to fractures if they fall due to a loss of
Cautions and contraindications common to the majority of bone density that occurs with ageing (Kaufman, 2013).
diuretics are listed in Box 2.
However, the Joint Formulary Committee (2013) and the Electrolyte imbalance
summaries of product characteristics for individual diuretics All diuretics can cause hyponatraemia (low serum sodium),
provide much more detailed information about cautions, but it is more common with thiazide diuretics (Khatib,
contraindications and side effects. The summaries of 2011). It is recommended that residents taking diuretics
product characteristics can be accessed at: www.medicines. serum sodium concentrations should be monitored (Har-
org.uk/emc vey and Jordan, 2010); urea and electrolytes should be
The following are examples of some of the most commonly monitored at least twice a year. A rapid fall in sodium can
encountered side effects. adversely affect brain cells and cause lethargy, headache,
anorexia, nausea, vomiting and confusion that can progress
Hypotension to seizures (Harvey and Jordan, 2010). In vulnerable older
All diuretics can cause hypotension and postural people with mildly impaired renal function, the loss of cir-
hypotension; therefore, blood pressure should be carefully culating fluid caused by administration of the diuretic can
monitored. It may be necessary to reduce the diuretic dose trigger the release of antidiuretic hormone, which in turn
to manage symptomatic hypotension (Khatib, 2011). causes water retention and resistance to diuretic therapy
However, sometimes this is difficult as failure worsens so the (Harvey and Jordan, 2010). Mild hyponatraemia may be as-
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dose can be split, e.g. 40 mg furosemide twice daily rather sociated with impaired gait, increasing the risk of falls and
than 80 mg in the morning. Co-administration of other fractures in older people (Harvey and Jordan, 2010).
drugs with diuretics and self-administered diuretics such as The administration of diuretics is associated with
tea, coffee and herbal remedies can also cause hypotension hypokalaemia (low serum potassium), which can have
(Harvey and Jordan, 2010). Special consideration should serious consequences, such as cardiac dysrhythmias or

NRC | February 2014, vol 16, no 2 85


CLINICAL REVIEW

arrest. Indications of a low serum potassium level include and Harvey, 2010). Administration at lunch time or later
palpitations, fatigue, depression, constipation and cramps can resolve the problem. Where divided doses are required
(Harvey and Jordan, 2010). Potassium-sparing diuretics can it is often most acceptable to give the second dose 68 hours
be prescribed if the serum potassium falls below 4 mmol/L. after the first (Bennett, 2008). Excessive diuresis can cause
Potassium supplements are rarely necessary and residents functional incontinence, and it is important that toilet facili-
should be advised to eat potassium-rich foods, such as fresh ties are close at hand when diuretics are first prescribed. In
vegetables, meat and fish (Harvey and Jordan, 2010). situations where diuresis is affecting quality of life, and dose
reduction is not an option, substitution with another diuret-
Renal impairment ic that has a longer duration of action may help to normalise
All classes of diuretics are implicated in precipitating renal micturition patterns (Harvey and Jordan, 2010).
impairment (Khatib, 2011). Consequently, renal function Diuretics are drugs that are frequently prescribed but
should be monitored carefully in patients taking diuretics. patients often stop taking them (Crouch and Chapelhow,
It is recommended that doses are reduced or diuretic ther- 2008). Poor adherence to diuretics may be associated with
apy is suspended temporarily if renal function deteriorates unpleasant adverse effects such as incontinence, impotence
(Khatib, 2011). or joint pains (Harvey and Jordan, 2010). It is essential that
Diuretics can also cause calcium and lipid imbalance and the diuretic prescribed is acceptable to the resident. Many
the loop and thiazide diuretics are associated with a rise in are given little information about the effects of diuretics
urate levels which can precipitate gout. Loop diuretics can and how best to manage them (Crouch and Chapelhow,
affect hearing and balance but this is usually reversible. 2008). It is important that health professionals explore the
Thiazide diuretics are associated with male impotence but effect of the diuretic on the residents lifestyle (Crouch and
this can also be caused by other drugs prescribed for car- Chapelhow, 2008; Harvey and Jordan, 2010). Adherence to
diovascular problems. In patients taking other drugs as well medication has important health benefits, which has been
as diuretics for cardiovascular problems, it is important to illustrated in large trials that demonstrate that diuretics save
establish exactly when the problem began (Harvey and Jor- and prolong lives for people with hypertension (Jordan and
dan, 2010). Harvey, 2010). On the other hand, non-adherence to diuret-
ics is implicated in the deterioration and hospitalisation of
Practical considerations individuals with heart failure (Harvey and Jordan, 2010).
When initiating diuretic therapy, there are a number of
practical considerations. Where possible, oral administra- Conclusion
tion should be linked to mealtimes to minimise gastrointes- Diuretics are drugs widely prescribed to reduce fluid
tinal upset (Harvey and Jordan, 2010). It is important to reabsorption in the kidneys and increase the loss of water
consider the diuretic effect and lifestyle of the resident when from the body. They are used in the management of
timing the dose of the diuretic (Bennett, 2008). It is essential conditions such as heart failure and hypertension. However,
that the diuretic effect does not interfere with the residents diuretics are associated with adverse effects and careful
sleep; therefore, once daily administration after waking is patient monitoring is required to ensure these drugs have a
often more appropriate than administration at other times therapeutic effect. In addition, health professionals have an
(Bennet, 2008). important role to play in promoting adherence and ensuring
However, some residents may find that morning adminis- that quality of life is not compromised for patients taking
tration exacerbates incontinence. This is because morning diuretics. NRC
administration results in drug-induced diuresis that coin-
cides with the natural 24hours rhythms in urine excretion This article has been subject to double-blind peer review.
(maximum diuresis occurs at approximately 8 am) (Jordan
Bennett S (2008) Diuretics: use, actions and prescribing rationale. Nurse Pre-
scribing 6(2): 727
Crouch S, Chapelhow C (2008) Medicines Management. A Nursing Perspective.
Pearson Education Limited, London
Greenstein B, Gould D (2009) Trounces Clinical Pharmacology for Nurses. 18th
Key points edn.Churchill Livingstone, London
Harvey S, Jordan S (2010) Diuretic therapy: implications for nursing practice.
Nurs Stand 24(43): 409
Diuretics are widely prescribed Hennefer D (2010) Pharmacologya systems approach: renal system. British
Journal of Healthcare Assistants 4(1): 3841
They are used in the treatment of hypertension and heart failure Joint Formulary Committee (2013) British National Formulary. No 66. BMJ
Group and RPS Publishing, London
Loop diuretics are the most powerful diuretics Kaufman G (2013) Prescribing and medicines management in older people.
A smaller diuresis is usually associated with thiazide diuretics compared to Nurs Older People 25(7): 3341
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Khatib R (2011) Prescribing diuretics in the management of heart failure.


loop diuretics Nurse Prescribing 9(9): 43541
Linden B (2011) NICE guidance on primary hypertension. British Journal of
Potassium sparing diuretics are the weakest of the diuretics and rarely used alone Cardiac Nursing 6(12): 5824
Diuretics are associated with adverse effects and patients taking them National Institute for Health and Care Excellence (2011) Hypertension, Clini-
cal management of primary hypertension in adults. NICE Clinical Guideline
should be monitored carefully 127. NICE, London
Simonsen T, Aarbakke J, Kay I, Coleman I, Sinnot P, Lysaa R (2006) Illustrated
Pharmacology for Nurses. Hodder Arnold, London

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