Combine ACEI with thiazide

for synergistic effect

Non-reabsorbable solutes increase

osmotic pressure of glomerular filtrate
inhibits reabsorption of water and
h urinary excretion of toxic materials

Cortical collecting duct

( Na+ reabsorption)

Renal tubules (proximal and

collecting duct)

Lungs
Tissues diffusely

Vascular smooth muscle, adrenal

cortex, proximal tubules

Direct renin antagonist

spironolactone (Aldactone)
triamterene (Dyrenium)
amiloride (Midamor)

Dyazide (triamterene + HCTZ)

Aldactazide (spironolactone
+ HCTZ)
Moduretic (amiloride + HCTZ)
Vaseretic (enalapril + HCTZ)
Zestoretic (lisinopril + HCTZ)

mannitol (Osmitrol)
glycerol
urea

ramipril (Altace)
enalapril (Vasotec)
lisinopril (Prinivil)
trandolapril (Mavik)
captopril (Capoten)

losartan (Cozaar)
candesartan (Atacand)
irbesartan (Avapro)
valsartan (Diovan)
telmisartan (Micardis)
eprosartan (Teveten)
olmesartan (Olmetec)

aliskiren (Rasilez)

Potassium-Sparing
Diuretics

Combination
Agents

Osmotic Diuretics

ACEI

ARB

Renin Antagonists

Inhibits renin production and activity

Cardioprotective and renoprotective
abilities being evaluated

HTN

HTN
Cardioprotective effects (see Cardiology and
Cardiac Surgery)
Renoprotective effects

HTN
Cardioprotective effects (see Cardiology and
Cardiac Surgery)
Renoprotective effects

aliskiren 150-300 mg PO OD

HTN:
losartan 25-100 mg PO OD
candesartan 8-32 mg PO OD
irbesartan 150-300 mg PO OD
valsartan 80-320 mg PO OD
telmisartan 20-80 mg PO OD
eprosartan 400-800 mg PO OD
olmesartan 20-40 mg PO OD

trandolapril: HTN: 1-4 mg PO OD

ramipril: HTN: 2.5-20 mg PO OD/bid

dosing
renoprotective use: 10 mg PO OD

mannitol:
i ICP: 0.25-2 g/kg IV over 30-60 min

spironolactone: 25-200 mg/d

OD/bid dosing
HTN: 50-200 mg/d OD/bid dosing
Hyperaldosteronism: 100-400 mg/d
OD/bid dosing
amiloride: edema/HTN: 5-10 mg PO OD

HCTZ:
edema: 25-100 mg PO OD
HTN: 12.5-25 mg PO OD
(max 50 mg/d)
nephrolithiasis/hypercalciuria:
25-100 mg OD

furosemide:
edema: 20-80 mg IV/IM/PO q6-8h
(max 600 mg/d) until desired response
HTN: 20-80 mg/d PO OD/bid dosing

Dosing

Hyperkalemia

Hyperkalemia
Caution reduce dose in hepatic impairment
AKI
Teratogenic

Cough
Asthma
Hyperkalemia
Angioedema
Agranulocytosis (captopril)
AKI
Teratogenic

Transient volume expansion

Electrolyte abnormalities ( i/h Na+, i/h K+)

Hyperkalemia (caution with ACEI)

Triamterene can be nephrotoxic (rare)
Nephrolithiasis
Gynecomastia (estrogenic effect of spironolactone)

Hypokalemia
Increased serum urate levels
Precipitates gouty attacks, hypercalcemia
Elevated lipids
Glucose intolerance

Allergy in sulfa-sensitive individuals

Electrolyte abnormalities; hypokalemia, hyponatremia,
hypocalcemia, hypercalciuria (with stone formation)
Volume depletion with metabolic alkalosis
Precipitates gouty attacks

Adverse Effects

Common Medications

Competitive inhibitor at the

angiotensin II receptor: prevents
angiotensin II vasoconstricting action
on vascular smooth muscle i BP
Prevents angiotensin II mediated
aldosterone release from adrenal
cortex and action on proximal renal
tubules h Na+ and H2O excretion

Prevents angiotensin II
vasoconstricting vascular smooth
muscle net vasodilation i BP
Prevents angiotensin II mediated
aldosterone release from adrenal
cortex and action on proximal renal
tubules
h Na+ and H2O excretion i BP
Reduces fibrosis and atherogenesis

To i intracranial or intraoccular pressure

Mobilization of excess fluid in renal failure or
edematous states

Combine K+-sparing drug with thiazide to

reduce hypokalemia

Reduces K+ loss caused by other diuretics

Edema/hypervolemia
Severe CHF, ascites (spironolactone),
cystic fibrosis (amiloride i viscosity of
secretions)

1st line for essential HTN

Treatment of edema
Idiopathic hypercalciuria and stones
Diabetes insipidus (nephrogenic)

Inhibit Na+/Cl transporter (K+ loss;

h H+ secretion; i Ca2+ excretion)

Distal convoluted tubule

hydrochlorothiazide (HCTZ)
chlorothiazide (Diuril)
indapamide (Lozol, Lozide)
metolazone (Zaroxolyn)
chlorthalidone (Hygroton)

Thiazide Diuretics

Aldosterone antagonist
Closes apical Na+ channels directly

Management of edema secondary to CHF,

nephrotic syndrome, cirrhotic ascites;
h free water clearance (e.g. in SIADH-induced
hyponatremia), i BP (less effective due to
short action)

i Na+/K+/2Cl transport renal

and peripheral vasodilatory effects
(K+ loss; h H+ secretion; h Ca2+
excretion)

Thick ascending limb of Loop

of Henle

furosemide (Lasix)
bumetanide (Bumex/Buinex)
ethacrynate (Edecrin)
torsemide (Demadex)

Indication

Loop Diuretics

Mechanism of Action
(Secondary Effect)

Site of Action

Examples

Classification

Table 16. Common Medications in Nephrology

NP38 Nephrology
Essential Med Notes 2015

Common Medications