Diuretic

Aka: Diuretic, Sulfa-based Diuretic, Hypokalemia in Diuretic Use, Prevention of Diuretic-Induced Hypokalemia

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II. Indications

  1. Common Indications
    1. Congestive Heart Failure
    2. Hypertension
    3. Chronic Kidney Disease
    4. Cirrhosis
  2. Other specific indications
    1. Acute Glaucoma
    2. Increased Intracranial Pressure (Mannitol)
    3. High Altitude Sickness (Acetazolamide)

III. Preparations

  1. Thiazide Diuretics
  2. Loop Diuretics
  3. Potassium-Sparing Diuretics
  4. Sulfonamide Diuretics: Metolazone (Zaroxolyn)

IV. Preparations: Related to Sulfa-base

  1. Hypersensitivity to SulfonamideAntibiotics does not confer other sulfa-based agent allergy
    1. May be safe to trial on sulfa-based agent despite prior Sulfa Antibiotic reaction
    2. Anaphylaxis to sulfa agent in past contraindicates repeat sulfa trial
    3. Strom (2003) N Engl J Med 349: 1628-35 [PubMed]
  2. Sulfa-based Diuretics
    1. Furosemide
    2. Torsemide
    3. Bumetanide
    4. All Thiazide Diuretics
  3. Non-sulfa based agents
    1. Potassium-Sparing Diuretics (e.g. Triamterene, Spironolactone, Amiloride)
    2. Ethacrynic Acid

V. Prevention: Hypokalemia in Diuretic Use

  1. See Potassium Replacement
  2. See Hypokalemia
  3. Monitoring
    1. Serum Potassium
      1. Obtain at baseline
      2. Repeat weekly when initiating high potency Diuretics (esp. Loop Diuretics, multiple Diuretics)
      3. Obtain periodically when stable on longterm Diuretics
        1. Every 3-4 months and as needed on high potency diurectics
        2. Every 6-12 months on Thiazide Diuretics (e.g. Hydrochlorothiazide, Chlorthalidone)
    2. Serum Magnesium
      1. Obtain at baseline and as needed for significant Hypokalemia
      2. Magnesium Replacement as needed
  4. Optimize concurrent medications that increase Serum Potassium
    1. ACE Inhibitors or Angiotensin Receptor Blockers
    2. Spironolactone
  5. Schedule Potassium Supplementation
    1. Adjust Potassium dose based on Diuretic dose and potency, Renal Function and baseline Serum Potassium
    2. Start Potassium chloride 20 meq orally daily when on Loop Diuretics
    3. Increase Potassium dosing as needed at times of increased Diuretic dosing
      1. When doubling the Diuretic dose, also double the Potassium chloride to 40 meq/day
      2. Monitor Potassium closely (weekly) after adjusting Diuretic and Potassium dosing
  6. References
    1. (2021) Presc Lett 28(8): 44
    2. Ferreira (2020) J Am Coll Cardiol 75(22):2836-50 +PMID: 32498812 [PubMed]

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