SlideShare ist ein Scribd-Unternehmen logo
1 von 20
Downloaden Sie, um offline zu lesen
DIURETICS How do they work? What do they do? When do I use them? HOW DO I USE THEM?
CONCEPT OF CEILING DOSE Ceiling [Diuretic] TL   Ceiling Effect Log [Diuretic] TL Fractional Excretion of Sodium (%)
CONCEPT OF CEILING DOSE Dose of Diuretic that Achieves a Ceiling [Diuretic] in the Tubular Lumen. Said Differently Dose of Diuretic that Yields a Near-Maximal Diuretic Response.
CONCEPT OF CEILING DOSE EFFECT < Ceiling Effect Ceiling Effect Ceiling Effect ACTUAL DOSE < Ceiling Dose Ceiling Dose > Ceiling Dose
CONCEPT OF CEILING DOSE Exceeding Ceiling Dose Yields: Pointless, and possibly harmful, to exceed ceiling dose of diuretic!! No Additional Effect Possible Adverse  Effects
DETERMINANTS OF CEILING DOSE VARIABLE ,[object Object],[object Object],[object Object],Increased Potency Decrease CEILING DOSE Decreased Tubular Transport (e.g., ARF/CRF) Increase Increased Binding to Urinary Proteins (e.g., Nephrotic Syndrome) Increase
CEILING DOSES FOR I.V. LOOP DIURETICS (in mgs) CIRRHOSIS HEART FAILURE 40 to 80 1 to 2 10 to 20 NEPHROTIC SYNDROME AFR/CRF Moderate AFR/CRF Severe 160 to 200 8 to 10 50 to 100 80 to 160 4 to 8 20 to 50 80 to 120 2 to 3 20 to 50 40 to 80 1 to 2 10 to 20 Furosemide Bumetanide Torsemide Protein Binding Increases Ceiling Dose Impaired Delivery Increases Ceiling Dose
CONVERTING I.V. DOSING TO ORAL DOSING BIOAVAILABILITY CONVERSION FACTOR ~ 50% (highly variable) ~ 100% ~ 100% 2 or higher 1 1 Furosemide Bumetanide Torsemide
DETERMINANTS OF CEILING EFFECT VARIABLE ,[object Object],[object Object],[object Object],Diuretic Loop > Thiazide > K-Sparing CEILING EFFECT Disease Diminished Nephron Response in Nephrotic Syndrome, Cirrhosis, & Heart Failure.
MECHANISMS OF DIURETIC RESISTANCE MECHANISM Patient Counseling SOLUTION Patient Counseling Push to Ceiling Dose Noncompliance NSAIDS Decreased Tubular Transport (e.g., ARF & CRF) Bed Rest Decreased RBF
MECHANISMS OF DIURETIC RESISTANCE (Continued) MECHANISM SOLUTION Bed Rest More Frequent Dosing or Continuous Infusion Combination Therapy (Sequential Blockade) Changes in “Volume Hormones” (SNS, RAS, ADH & ANF) Compensation by Distal Nephron Diminished Nephron Response (CHF, Cirrhosis, Nephrotic Syndrome)
MECHANISMS OF DIURETIC RESISTANCE Proximal Distal Na Na Proximal Distal Na Proximal Distal Na Na Na Proximal Distal Na Na Acute Loop Chronic Loop Chronic Loop +  Thiazide
MECHANISMS OF DIURETIC RESISTANCE (Continued) MECHANISM SOLUTION Bed Rest More Frequent Dosing or Continuous Infusion Combination Therapy (Sequential Blockade) Changes in “Volume Hormones” (SNS, RAS, ADH & ANF) Compensation by Distal Nephron Diminished Nephron Response (CHF, Cirrhosis, Nephrotic Syndrome)
RATIONALE FOR MORE FREQUENT DOSING OR CONTINUOUS I.V. INFUSION [Diuretic] TL Ceiling [Diuretic] TL [Diuretic] TL Ceiling Ceiling
CEILING DOSES FOR CONTINUOUS I.V. INFUSION OF LOOP DIURETICS (in mgs per hour) LOADING DOSE (in mgs) CrCl < 25 10 0.5 5 10 to 20 0.5 to 1 5 to 10 20 to 40 1 to 2 10 to 20 40 1 20 Furosemide Bumetanide Torsemide CrCl: 25 to 75 CrCl > 75
WHAT HAPPENS WHEN [DIURETIC] IN TUBULAR LUMEN IS LESS THAN CEILING?? Postdiuresis Sodium Retention!!
RATIONALE FOR LOW SODIUM DIET A low sodium diet attenuates postdiuretic sodium retention, thereby lowering diuretic requirements!! Major Problem is Compliance
IMPORTANT DRUG  INTERACTIONS NSAIDS Salt Decongestants Probenecid Hyperkalemia- Induced by K-Sparing Diuretics Enhanced Ototoxicity of Loop Diuretic Diminished Diuretic Response ACE Inhibitors Beta-Blockers K Supplements K-Sparing Diuretics Heparin Ototoxic Drugs
ARF/CRF Nephrotic Syndrome Cirrhosis Mild CHF Severe/Moderate  CHF ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],While Maintaining Other Diuretics, Switch Loop Agent to Continuous Infusion Spironolactone Titrated to 400 mg Daily. ,[object Object],[object Object],[object Object]
 

Weitere ähnliche Inhalte

Was ist angesagt?

Thiazide diuretics (chlorothiazide)
Thiazide diuretics (chlorothiazide)Thiazide diuretics (chlorothiazide)
Thiazide diuretics (chlorothiazide)Rifat Zakir
 
Pharmacology of diuretics-antidiuretics
Pharmacology of diuretics-antidiureticsPharmacology of diuretics-antidiuretics
Pharmacology of diuretics-antidiureticsKola Phani Kumar
 
CARBONIC ANHYDRASE INHIBITOR: DIURETICS ACT ON PCT(proximal convoluted tubule)
CARBONIC ANHYDRASE  INHIBITOR: DIURETICS ACT ON PCT(proximal  convoluted tubule)CARBONIC ANHYDRASE  INHIBITOR: DIURETICS ACT ON PCT(proximal  convoluted tubule)
CARBONIC ANHYDRASE INHIBITOR: DIURETICS ACT ON PCT(proximal convoluted tubule)Gourab Banerjee
 
Nurses responsibilities on Diuretics
Nurses responsibilities on   DiureticsNurses responsibilities on   Diuretics
Nurses responsibilities on DiureticsMathew Varghese V
 
Urinary System Drugs
Urinary System DrugsUrinary System Drugs
Urinary System Drugsguest9bc2b8
 
Diuretics, cardiovascular drugs, antiplatelets n anticoagulant.
Diuretics, cardiovascular drugs, antiplatelets n anticoagulant.Diuretics, cardiovascular drugs, antiplatelets n anticoagulant.
Diuretics, cardiovascular drugs, antiplatelets n anticoagulant.soumyakanta
 
Part I - How Do They Work
Part I - How Do They WorkPart I - How Do They Work
Part I - How Do They Workpharmdude
 
Diuretics : Dr Renuka Joshi MD,DNB, (FNB )
Diuretics : Dr Renuka Joshi MD,DNB, (FNB )Diuretics : Dr Renuka Joshi MD,DNB, (FNB )
Diuretics : Dr Renuka Joshi MD,DNB, (FNB )Renuka Buche
 
Diuretics REVISION NOTES
Diuretics REVISION NOTES Diuretics REVISION NOTES
Diuretics REVISION NOTES TONY SCARIA
 
Clinical pharmacology of diuretic agents
Clinical pharmacology of diuretic agentsClinical pharmacology of diuretic agents
Clinical pharmacology of diuretic agentsDomina Petric
 
Diuretics presentation by DVM student Hamza Jawad
Diuretics presentation by DVM student Hamza JawadDiuretics presentation by DVM student Hamza Jawad
Diuretics presentation by DVM student Hamza JawadDr Hamza Jawad
 
NurseReview.Org - Diuretics Updates (pharmacology worksheets)
NurseReview.Org - Diuretics Updates (pharmacology worksheets)NurseReview.Org - Diuretics Updates (pharmacology worksheets)
NurseReview.Org - Diuretics Updates (pharmacology worksheets)jben501
 

Was ist angesagt? (20)

Thiazide diuretics (chlorothiazide)
Thiazide diuretics (chlorothiazide)Thiazide diuretics (chlorothiazide)
Thiazide diuretics (chlorothiazide)
 
Pharmacology of diuretics-antidiuretics
Pharmacology of diuretics-antidiureticsPharmacology of diuretics-antidiuretics
Pharmacology of diuretics-antidiuretics
 
Diuretics
DiureticsDiuretics
Diuretics
 
CARBONIC ANHYDRASE INHIBITOR: DIURETICS ACT ON PCT(proximal convoluted tubule)
CARBONIC ANHYDRASE  INHIBITOR: DIURETICS ACT ON PCT(proximal  convoluted tubule)CARBONIC ANHYDRASE  INHIBITOR: DIURETICS ACT ON PCT(proximal  convoluted tubule)
CARBONIC ANHYDRASE INHIBITOR: DIURETICS ACT ON PCT(proximal convoluted tubule)
 
DIURETICS PNA---PDF
DIURETICS PNA---PDFDIURETICS PNA---PDF
DIURETICS PNA---PDF
 
Nurses responsibilities on Diuretics
Nurses responsibilities on   DiureticsNurses responsibilities on   Diuretics
Nurses responsibilities on Diuretics
 
Urinary System Drugs
Urinary System DrugsUrinary System Drugs
Urinary System Drugs
 
3.Diuretics
3.Diuretics3.Diuretics
3.Diuretics
 
09 Diuretics Upd
09 Diuretics Upd09 Diuretics Upd
09 Diuretics Upd
 
Diuretics, cardiovascular drugs, antiplatelets n anticoagulant.
Diuretics, cardiovascular drugs, antiplatelets n anticoagulant.Diuretics, cardiovascular drugs, antiplatelets n anticoagulant.
Diuretics, cardiovascular drugs, antiplatelets n anticoagulant.
 
Part I - How Do They Work
Part I - How Do They WorkPart I - How Do They Work
Part I - How Do They Work
 
Diuretics : Dr Renuka Joshi MD,DNB, (FNB )
Diuretics : Dr Renuka Joshi MD,DNB, (FNB )Diuretics : Dr Renuka Joshi MD,DNB, (FNB )
Diuretics : Dr Renuka Joshi MD,DNB, (FNB )
 
Diuretics REVISION NOTES
Diuretics REVISION NOTES Diuretics REVISION NOTES
Diuretics REVISION NOTES
 
Clinical pharmacology of diuretic agents
Clinical pharmacology of diuretic agentsClinical pharmacology of diuretic agents
Clinical pharmacology of diuretic agents
 
Diuretics presentation by DVM student Hamza Jawad
Diuretics presentation by DVM student Hamza JawadDiuretics presentation by DVM student Hamza Jawad
Diuretics presentation by DVM student Hamza Jawad
 
Diuretics
DiureticsDiuretics
Diuretics
 
Lecture 2 adithan diuretics july 29, 2016 mgmcri
Lecture 2 adithan diuretics july 29, 2016 mgmcriLecture 2 adithan diuretics july 29, 2016 mgmcri
Lecture 2 adithan diuretics july 29, 2016 mgmcri
 
Diuretics
DiureticsDiuretics
Diuretics
 
Diuretics
DiureticsDiuretics
Diuretics
 
NurseReview.Org - Diuretics Updates (pharmacology worksheets)
NurseReview.Org - Diuretics Updates (pharmacology worksheets)NurseReview.Org - Diuretics Updates (pharmacology worksheets)
NurseReview.Org - Diuretics Updates (pharmacology worksheets)
 

Andere mochten auch

Diuretic strategies in AHF : dose dose matter ?
Diuretic strategies in AHF : dose dose matter ?Diuretic strategies in AHF : dose dose matter ?
Diuretic strategies in AHF : dose dose matter ?drucsamal
 
Diuretic strategies in patients with acute decompensated
Diuretic  strategies  in  patients  with  acute  decompensatedDiuretic  strategies  in  patients  with  acute  decompensated
Diuretic strategies in patients with acute decompensatedWarawut Ia
 
Atorvastatin & dyslipidemia
Atorvastatin & dyslipidemiaAtorvastatin & dyslipidemia
Atorvastatin & dyslipidemiaMUPEG
 
NurseReview.Org Pharmacology Bullet Review
NurseReview.Org Pharmacology Bullet ReviewNurseReview.Org Pharmacology Bullet Review
NurseReview.Org Pharmacology Bullet ReviewNurse ReviewDotOrg
 
Diuretics in hypertension 2015 by Dr Abhishek Rathore
Diuretics in hypertension 2015 by Dr Abhishek RathoreDiuretics in hypertension 2015 by Dr Abhishek Rathore
Diuretics in hypertension 2015 by Dr Abhishek Rathoredrabhishekbabbu
 
Atorvastatin
AtorvastatinAtorvastatin
Atorvastatinkenny_gwc
 
NurseReview.Org Pharmacology - Kidney Drugs
NurseReview.Org Pharmacology - Kidney DrugsNurseReview.Org Pharmacology - Kidney Drugs
NurseReview.Org Pharmacology - Kidney DrugsNurse ReviewDotOrg
 
Ace inhibitors
Ace inhibitorsAce inhibitors
Ace inhibitorsgabarian
 
Diuretics by P.Ravisankar
Diuretics by P.RavisankarDiuretics by P.Ravisankar
Diuretics by P.RavisankarDr. Ravi Sankar
 
dosage forms and route of drug administration
 dosage forms and route of drug administration dosage forms and route of drug administration
dosage forms and route of drug administrationAbubakar Fago
 

Andere mochten auch (14)

Diuretic strategies in AHF : dose dose matter ?
Diuretic strategies in AHF : dose dose matter ?Diuretic strategies in AHF : dose dose matter ?
Diuretic strategies in AHF : dose dose matter ?
 
Diuretic strategies in patients with acute decompensated
Diuretic  strategies  in  patients  with  acute  decompensatedDiuretic  strategies  in  patients  with  acute  decompensated
Diuretic strategies in patients with acute decompensated
 
Unipril (Ramipril) ppt
Unipril (Ramipril) pptUnipril (Ramipril) ppt
Unipril (Ramipril) ppt
 
Atorvastatin & dyslipidemia
Atorvastatin & dyslipidemiaAtorvastatin & dyslipidemia
Atorvastatin & dyslipidemia
 
NurseReview.Org Pharmacology Bullet Review
NurseReview.Org Pharmacology Bullet ReviewNurseReview.Org Pharmacology Bullet Review
NurseReview.Org Pharmacology Bullet Review
 
Atorvastatin
AtorvastatinAtorvastatin
Atorvastatin
 
Diuretics in hypertension 2015 by Dr Abhishek Rathore
Diuretics in hypertension 2015 by Dr Abhishek RathoreDiuretics in hypertension 2015 by Dr Abhishek Rathore
Diuretics in hypertension 2015 by Dr Abhishek Rathore
 
Basic Pharmacology of Diuretics
Basic Pharmacology of DiureticsBasic Pharmacology of Diuretics
Basic Pharmacology of Diuretics
 
Atorvastatin
AtorvastatinAtorvastatin
Atorvastatin
 
Diuretics
DiureticsDiuretics
Diuretics
 
NurseReview.Org Pharmacology - Kidney Drugs
NurseReview.Org Pharmacology - Kidney DrugsNurseReview.Org Pharmacology - Kidney Drugs
NurseReview.Org Pharmacology - Kidney Drugs
 
Ace inhibitors
Ace inhibitorsAce inhibitors
Ace inhibitors
 
Diuretics by P.Ravisankar
Diuretics by P.RavisankarDiuretics by P.Ravisankar
Diuretics by P.Ravisankar
 
dosage forms and route of drug administration
 dosage forms and route of drug administration dosage forms and route of drug administration
dosage forms and route of drug administration
 

Ähnlich wie IV - How Do I Use Them

Diuretic resistance im lecture series 2016
Diuretic resistance  im lecture series 2016Diuretic resistance  im lecture series 2016
Diuretic resistance im lecture series 2016Jedrek Wosik, MD
 
Diuretics by Dr. Sookun Rajeev Kumar M.D
Diuretics by Dr. Sookun Rajeev Kumar M.DDiuretics by Dr. Sookun Rajeev Kumar M.D
Diuretics by Dr. Sookun Rajeev Kumar M.DDr. Sookun Rajeev Kumar
 
Diuretic agents outline
Diuretic agents outlineDiuretic agents outline
Diuretic agents outlineraj kumar
 
acute-kidney-injury.ppt
acute-kidney-injury.pptacute-kidney-injury.ppt
acute-kidney-injury.pptNekHang
 
Intravenous Anaesthetics (Intro)
Intravenous Anaesthetics (Intro)Intravenous Anaesthetics (Intro)
Intravenous Anaesthetics (Intro)Andrew Ferguson
 
antihypertensive aliza.pdf
antihypertensive aliza.pdfantihypertensive aliza.pdf
antihypertensive aliza.pdfRohitNewar1
 
L6-diuretics final-2014-k sparing diuretics.ppt
L6-diuretics final-2014-k sparing diuretics.pptL6-diuretics final-2014-k sparing diuretics.ppt
L6-diuretics final-2014-k sparing diuretics.pptManjushaShinde14
 
Muhammad Sufyan Akram
Muhammad Sufyan AkramMuhammad Sufyan Akram
Muhammad Sufyan AkramMSufyan3
 
Antihypertensives. Drugs to use for hpdf
Antihypertensives. Drugs to use for hpdfAntihypertensives. Drugs to use for hpdf
Antihypertensives. Drugs to use for hpdflilyramlakhan1
 
Pharmacotherapy of heart failure
Pharmacotherapy of heart failure Pharmacotherapy of heart failure
Pharmacotherapy of heart failure Nidhi Maheshwari
 

Ähnlich wie IV - How Do I Use Them (20)

Diuretic resistence
Diuretic resistenceDiuretic resistence
Diuretic resistence
 
Diureticresistence
DiureticresistenceDiureticresistence
Diureticresistence
 
Diuretics
DiureticsDiuretics
Diuretics
 
Diuretic resistance im lecture series 2016
Diuretic resistance  im lecture series 2016Diuretic resistance  im lecture series 2016
Diuretic resistance im lecture series 2016
 
Diuretics by Dr. Sookun Rajeev Kumar M.D
Diuretics by Dr. Sookun Rajeev Kumar M.DDiuretics by Dr. Sookun Rajeev Kumar M.D
Diuretics by Dr. Sookun Rajeev Kumar M.D
 
Diuretic agents outline
Diuretic agents outlineDiuretic agents outline
Diuretic agents outline
 
Drugs And The Kidney
Drugs And The KidneyDrugs And The Kidney
Drugs And The Kidney
 
acute-kidney-injury.ppt
acute-kidney-injury.pptacute-kidney-injury.ppt
acute-kidney-injury.ppt
 
acute-kidney-injury.ppt
acute-kidney-injury.pptacute-kidney-injury.ppt
acute-kidney-injury.ppt
 
Diuretics
DiureticsDiuretics
Diuretics
 
Intravenous Anaesthetics (Intro)
Intravenous Anaesthetics (Intro)Intravenous Anaesthetics (Intro)
Intravenous Anaesthetics (Intro)
 
PHARMACOLOGY OF ANTIDIURETICS
PHARMACOLOGY OF ANTIDIURETICS   PHARMACOLOGY OF ANTIDIURETICS
PHARMACOLOGY OF ANTIDIURETICS
 
Elderly and Diuretics
Elderly and DiureticsElderly and Diuretics
Elderly and Diuretics
 
Diuretics in CKD
Diuretics in CKDDiuretics in CKD
Diuretics in CKD
 
antihypertensive aliza.pdf
antihypertensive aliza.pdfantihypertensive aliza.pdf
antihypertensive aliza.pdf
 
Hypertension
HypertensionHypertension
Hypertension
 
L6-diuretics final-2014-k sparing diuretics.ppt
L6-diuretics final-2014-k sparing diuretics.pptL6-diuretics final-2014-k sparing diuretics.ppt
L6-diuretics final-2014-k sparing diuretics.ppt
 
Muhammad Sufyan Akram
Muhammad Sufyan AkramMuhammad Sufyan Akram
Muhammad Sufyan Akram
 
Antihypertensives. Drugs to use for hpdf
Antihypertensives. Drugs to use for hpdfAntihypertensives. Drugs to use for hpdf
Antihypertensives. Drugs to use for hpdf
 
Pharmacotherapy of heart failure
Pharmacotherapy of heart failure Pharmacotherapy of heart failure
Pharmacotherapy of heart failure
 

Mehr von pharmdude

Inman_Stem_Cells_05
Inman_Stem_Cells_05Inman_Stem_Cells_05
Inman_Stem_Cells_05pharmdude
 
SC_Adv_research
SC_Adv_researchSC_Adv_research
SC_Adv_researchpharmdude
 
Stem cell ethics 06
Stem cell ethics 06Stem cell ethics 06
Stem cell ethics 06pharmdude
 
2008-0471S1-4
2008-0471S1-42008-0471S1-4
2008-0471S1-4pharmdude
 
fall 2008 1110
fall 2008 1110fall 2008 1110
fall 2008 1110pharmdude
 
education_11-24
education_11-24education_11-24
education_11-24pharmdude
 
Part III - When Do I Use Them
Part III - When Do I Use ThemPart III - When Do I Use Them
Part III - When Do I Use Thempharmdude
 
2007aquilante-persmed
2007aquilante-persmed2007aquilante-persmed
2007aquilante-persmedpharmdude
 
Woods Anticoag Antianem 09
Woods Anticoag Antianem 09Woods Anticoag Antianem 09
Woods Anticoag Antianem 09pharmdude
 
att4_Rice_Sep07
att4_Rice_Sep07att4_Rice_Sep07
att4_Rice_Sep07pharmdude
 
INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part IV - Adrenergic
INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part IV - Adrenergic INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part IV - Adrenergic
INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part IV - Adrenergic pharmdude
 
INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part V - Actions of a
INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part V - Actions of aINTRODUCTION TO AUTONOMIC PHARMACOLOGY Part V - Actions of a
INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part V - Actions of apharmdude
 
INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part III - Mechanism
INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part III - Mechanism INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part III - Mechanism
INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part III - Mechanism pharmdude
 
INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part II - Anatomy of
INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part II - Anatomy of INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part II - Anatomy of
INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part II - Anatomy of pharmdude
 

Mehr von pharmdude (20)

Inman_Stem_Cells_05
Inman_Stem_Cells_05Inman_Stem_Cells_05
Inman_Stem_Cells_05
 
SC_Adv_research
SC_Adv_researchSC_Adv_research
SC_Adv_research
 
L24
L24L24
L24
 
Stem cell ethics 06
Stem cell ethics 06Stem cell ethics 06
Stem cell ethics 06
 
ss10
ss10ss10
ss10
 
2008-0471S1-4
2008-0471S1-42008-0471S1-4
2008-0471S1-4
 
CHARO
CHAROCHARO
CHARO
 
fall 2008 1110
fall 2008 1110fall 2008 1110
fall 2008 1110
 
1
11
1
 
education_11-24
education_11-24education_11-24
education_11-24
 
Part III - When Do I Use Them
Part III - When Do I Use ThemPart III - When Do I Use Them
Part III - When Do I Use Them
 
2007aquilante-persmed
2007aquilante-persmed2007aquilante-persmed
2007aquilante-persmed
 
lect-anian
lect-anianlect-anian
lect-anian
 
Woods Anticoag Antianem 09
Woods Anticoag Antianem 09Woods Anticoag Antianem 09
Woods Anticoag Antianem 09
 
att4_Rice_Sep07
att4_Rice_Sep07att4_Rice_Sep07
att4_Rice_Sep07
 
INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part IV - Adrenergic
INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part IV - Adrenergic INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part IV - Adrenergic
INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part IV - Adrenergic
 
INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part V - Actions of a
INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part V - Actions of aINTRODUCTION TO AUTONOMIC PHARMACOLOGY Part V - Actions of a
INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part V - Actions of a
 
INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part III - Mechanism
INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part III - Mechanism INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part III - Mechanism
INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part III - Mechanism
 
INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part II - Anatomy of
INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part II - Anatomy of INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part II - Anatomy of
INTRODUCTION TO AUTONOMIC PHARMACOLOGY Part II - Anatomy of
 
chapter 16
chapter 16chapter 16
chapter 16
 

Kürzlich hochgeladen

Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024EwoutSteyerberg1
 
pA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologypA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologyDeepakDaniel9
 
AORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectionAORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectiondrhanifmohdali
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.pptRamDBawankar1
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondSujoy Dasgupta
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.whalesdesign
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .Mohamed Rizk Khodair
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdfHongBiThi1
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptPradnya Wadekar
 
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.aarjukhadka22
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxkomalt2001
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfHongBiThi1
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)kishan singh tomar
 
BENIGN BREAST DISEASE
BENIGN BREAST DISEASE BENIGN BREAST DISEASE
BENIGN BREAST DISEASE Mamatha Lakka
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionkrishnareddy157915
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...Sujoy Dasgupta
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfHongBiThi1
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu Medical University
 

Kürzlich hochgeladen (20)

Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024
 
pA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologypA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacology
 
AORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectionAORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissection
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and Beyond
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.
 
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologyppt
 
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptx
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)
 
BENIGN BREAST DISEASE
BENIGN BREAST DISEASE BENIGN BREAST DISEASE
BENIGN BREAST DISEASE
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung function
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
 
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu
 

IV - How Do I Use Them

  • 1. DIURETICS How do they work? What do they do? When do I use them? HOW DO I USE THEM?
  • 2. CONCEPT OF CEILING DOSE Ceiling [Diuretic] TL Ceiling Effect Log [Diuretic] TL Fractional Excretion of Sodium (%)
  • 3. CONCEPT OF CEILING DOSE Dose of Diuretic that Achieves a Ceiling [Diuretic] in the Tubular Lumen. Said Differently Dose of Diuretic that Yields a Near-Maximal Diuretic Response.
  • 4. CONCEPT OF CEILING DOSE EFFECT < Ceiling Effect Ceiling Effect Ceiling Effect ACTUAL DOSE < Ceiling Dose Ceiling Dose > Ceiling Dose
  • 5. CONCEPT OF CEILING DOSE Exceeding Ceiling Dose Yields: Pointless, and possibly harmful, to exceed ceiling dose of diuretic!! No Additional Effect Possible Adverse Effects
  • 6.
  • 7. CEILING DOSES FOR I.V. LOOP DIURETICS (in mgs) CIRRHOSIS HEART FAILURE 40 to 80 1 to 2 10 to 20 NEPHROTIC SYNDROME AFR/CRF Moderate AFR/CRF Severe 160 to 200 8 to 10 50 to 100 80 to 160 4 to 8 20 to 50 80 to 120 2 to 3 20 to 50 40 to 80 1 to 2 10 to 20 Furosemide Bumetanide Torsemide Protein Binding Increases Ceiling Dose Impaired Delivery Increases Ceiling Dose
  • 8. CONVERTING I.V. DOSING TO ORAL DOSING BIOAVAILABILITY CONVERSION FACTOR ~ 50% (highly variable) ~ 100% ~ 100% 2 or higher 1 1 Furosemide Bumetanide Torsemide
  • 9.
  • 10. MECHANISMS OF DIURETIC RESISTANCE MECHANISM Patient Counseling SOLUTION Patient Counseling Push to Ceiling Dose Noncompliance NSAIDS Decreased Tubular Transport (e.g., ARF & CRF) Bed Rest Decreased RBF
  • 11. MECHANISMS OF DIURETIC RESISTANCE (Continued) MECHANISM SOLUTION Bed Rest More Frequent Dosing or Continuous Infusion Combination Therapy (Sequential Blockade) Changes in “Volume Hormones” (SNS, RAS, ADH & ANF) Compensation by Distal Nephron Diminished Nephron Response (CHF, Cirrhosis, Nephrotic Syndrome)
  • 12. MECHANISMS OF DIURETIC RESISTANCE Proximal Distal Na Na Proximal Distal Na Proximal Distal Na Na Na Proximal Distal Na Na Acute Loop Chronic Loop Chronic Loop + Thiazide
  • 13. MECHANISMS OF DIURETIC RESISTANCE (Continued) MECHANISM SOLUTION Bed Rest More Frequent Dosing or Continuous Infusion Combination Therapy (Sequential Blockade) Changes in “Volume Hormones” (SNS, RAS, ADH & ANF) Compensation by Distal Nephron Diminished Nephron Response (CHF, Cirrhosis, Nephrotic Syndrome)
  • 14. RATIONALE FOR MORE FREQUENT DOSING OR CONTINUOUS I.V. INFUSION [Diuretic] TL Ceiling [Diuretic] TL [Diuretic] TL Ceiling Ceiling
  • 15. CEILING DOSES FOR CONTINUOUS I.V. INFUSION OF LOOP DIURETICS (in mgs per hour) LOADING DOSE (in mgs) CrCl < 25 10 0.5 5 10 to 20 0.5 to 1 5 to 10 20 to 40 1 to 2 10 to 20 40 1 20 Furosemide Bumetanide Torsemide CrCl: 25 to 75 CrCl > 75
  • 16. WHAT HAPPENS WHEN [DIURETIC] IN TUBULAR LUMEN IS LESS THAN CEILING?? Postdiuresis Sodium Retention!!
  • 17. RATIONALE FOR LOW SODIUM DIET A low sodium diet attenuates postdiuretic sodium retention, thereby lowering diuretic requirements!! Major Problem is Compliance
  • 18. IMPORTANT DRUG INTERACTIONS NSAIDS Salt Decongestants Probenecid Hyperkalemia- Induced by K-Sparing Diuretics Enhanced Ototoxicity of Loop Diuretic Diminished Diuretic Response ACE Inhibitors Beta-Blockers K Supplements K-Sparing Diuretics Heparin Ototoxic Drugs
  • 19.
  • 20.