Aldosterone antagonists have been shown to be cardioprotective in patients with heart disease. In addition, they may exert an additional benefit in lowering albuminuria in patients with diabetes and microalbuminuria. Their use has been limited in patients with renal dysfunction because of the increased risk of inducing hyperkalemia. Finerenone may afford similar cardiac and renal protection with a lower risk for hyperkalemia.
• Brinzolamide, dorzolamide: Topical for glaucoma
SGLT2 INHIBITORS •CanagliflozinInhibition of sodium/glucose cotransporter (SGLT2) in the PCT results in decreased Na+ and glucose reabsorption Inhibition of glucose reabsorption lowers serum glucose concentration, and reduced Na+ reabsorption causes mild diuresis Diabetes mellitus; approved for the treatment of hyperglycemia, not as a diuretic Available orally. Half-life 10–12h•notrecommendedin severe renal or liver disease •Dapagliflozin, empagliflozin: similar to canagliflozin
Bumetanide, torsemide: Sulfonamide loop agents like furosemide
Ethacrynic acid: Not a sulfonamide but has typical loop activity and some uricosuric action
Pulmonary edema, peripheral edema, heart failure, hypertension, acute hypercalcemia, anion overdose Oral and parenteral preparations • duration of action 2–4 h • Toxicity:
Ototoxicity, hypovolemia, K wasting, hyperuricemia, hypomagnesemia
Inhibition of the Na/Cl transporter in the distal convoluted tubule
Hypertension, mild heart failure, nephrolithiasis, nephrogenic diabetes insipidus • Toxicity: Hypokalemic metabolic alkalosis, hyperuricemia, hyperglycemia, hyponatremia
Metolazone: Popular for use with loop agents for synergistic effects
Chlorothiazide: Only parenteral thiazide available (IV)
Chlorthalidone: Long half-life (50–60 h) due to binding to red blood cells
Eplerenone: Like spironolactone, more selective for aldosterone receptor
Triamterene: Mechanism like amiloride, much less potent, more toxic
POTASSIUM-SPARING DIURETICS •SpironolactonePharmacologic antagonist of aldosterone in collecting tubules•weakantagonismof androgen receptors Reduces Na retention and K wasting in kidney•poorlyunderstoodantagonismofaldosterone in heart and vessels Aldosteronism from any cause •hypokalemiaduetoother diuretics •postmyocardialinfarction Slow onset and offset of effect•duration24–48h•Toxicity: Hyperkalemia, gynecomastia (spironolactone, not eplerenone)•additiveinteraction with other K-retaining drugs •AmilorideBlocks epithelial sodium channels in collecting tubules Reduces Na retention and K wasting •increaseslithiumclearanceHypokalemia from other diuretics •reduceslithium-induced polyuria •Liddle’ssyndromeOrallyactive•duration24h•Toxicity: Hyperkalemic metabolic acidosis
Acetazolamide Generic, Diamox
Amiloride Generic, Midamor, combination drugs*
Bendroflumethiazide Naturetin, combination drugs *
Bumetanide Generic, Bumex Dapagliflozin Farxiga Chlorthalidone Generic, Hygroton, Thalitone,
Chlorothiazide Generic, Diuril combination drugs * Demeclocycline Generic, Declomycin Dorzolamide (for ocular Generic, Trusopt
Hydrochlorothiazide Generic, Esidrix, Hydro-DIURIL, combination drugs *