Drugs Affecting the Renal System GROUP 6 Objectives: • Understand the necessary patient monitoring and assessment parameters when patients are prescribed drugs affecting the renal system • Recognize the medical conditions and indications for which renal system drugs are prescribed • Continuously assess and improve your knowledge and practice related to drugs affecting the renal system to provide the highest quality of care to patients DIURETICS DRUG Are medicines that help reduce fluid buildup in the body. A diuretic is any substance that promotes diuresis, the increased production of urine. This includes forced diuresis. A diuretic tablet is sometimes colloquially called a water tablet. There are several categories of diuretics. All diuretics increase the excretion of water from the body, through the kidneys There are five types of Diuretics • LOOP OR HIGH DIURETICS • THIAZIDE DIURETICS • POTASSIUM SPARING DIURETICS • OSMOTIC DIURETICS • CARBONIC ANHYDRASE INHIBITORS LOOP OR HIGH DIURETICS Drug names: 1. GENERIC NAME • Bumetanide • Furosemide • Torsemide 2. BRAND NAME • Bumex • Lasix • Soaanz Drug Dosage Bumetanide Injectable solution • • • • Torsemide Tablet 0.25mg/mL tablet 0.5mg 1mg 2mg • 5mg • 10mg • 20mg Furosemide Oral solution or Tablets • Adults - 20 to 80 mg • Children - 2 mg For high blood pressure • 40 mg Mechanism of action • high ceiling diuretics may cause a substantial diureses up to 20% • this a large in comparison to normal renal sodium reabsorption which leaves only about 0.4 % • They act by diminishing sodium reabsorption at different sites in the nephron, thereby increasing urinary sodium and water losses Indications • HYPERTENSION • EDEMA ASSOCIATED • RENAL CALCIUM • CEREBRAL EDEMA • HYPERCALCEMIA Contraindicati on • ELECTROLYTE IMBALANCE • SEVERE RENAL FAILURE • HEPATIC COMA Side Effects/ Adverse effects • Hypokalemic metabolic alkalosis (hypokalemia) • Ototoxicity • Hyperuricemia • Hypomagnesemia • Allergic reactions • Dizziness • Postural hypotension • Syncope Nursing Intervention • Monitor urinary output to determine body fluid gain or loss. Urinary output should be at least 30 mL/h or 600 mL/24 h. • Notify a health care provider if urine output does not increase; a severe renal disorder may be present. • Weigh the patient to determine fluid loss or gain. A loss of 2.2 lb is equivalent to a fluid loss of 1L. • Monitor vital signs, and be alert for marked decreases in blood pressure. • Administer IV furosemide slowly; hearing loss may occur if it is rapidly injected. • Observe for signs and symptoms of hypokalemia (< 3.5 mEq/L), such as muscle weakness, abdominal distension, leg cramps, and/or cardiac dysrhythmias. • Monitor serum potassium levels, especially when a patient is taking digoxin. Hypokalemia enhances the action of digitalis, causing digitalis toxicity. THIAZIDE DIURETICS Generic Name • Chlorthalidone • Indapamide • Metolazone Brand Name • Hygroton • Lozol • Mykrox Drug Dosage Metolazone Tablet • 2.5mg • 5mg • 10mg Hypertension • 2.5mg Edema • 2. 5 - 10mg PO Chlorthalidine Tablets • Adults- 50 - 100 mg For high blood pressure • Adults- 25 mg Indapamide Tablets • 1.25mg • 2.5mg Edema 2.5 mg PO Hypertension 1.25 mg PO Mechanism of Action • T h i az i de di u r e t i c s e x e r t t h e i r di u r e t i c e ff e c t vi a b l o c k a g e o f t h e s o d i u m - c h l o r i d e ( N a / C l ) channel in the proximal segment of the distal c o nvo l u t e d t u b u l e ( D C T ) . • Its effects on the nephron will be more thoroughly discussed below and will be r e fe r r e d t o i n t h e adve r s e e ffe c t s s e c t i o n . INDICATIONS • Indicated as adjunctive therapy to treat edema associated with congestive heart failure, hepatic cirrhosis, corticosteroid, and estrogen therapy. ( FDA-approved) CONTRAINDICATIONS • Indicated to treat edema associated with renal dysfunction. ( FDA-approved) • Indicated to treat hypertension as a sole agent or adjunct. • Severe renal impairment • Severe hepatic impairment • hypersensitivity • Pregnancy and Lactation • Allergies Side Effects/ Adverse effects • dizziness and lightheadedness, • Hypokalemia • blurred vision, • Hyponatremia • loss of appetite, • Metabolic alkalosis • itching, • Hypercalcemi • stomach upset, • Hyperglycemia • headache, and • Hyperuricemia • weakness • Hyperlipidemia • Sulfonamide allergy NURSING INTERVENTION • Emphasize the need for adherence to the therapy plan. The patient may not feel better for some time or may not feel worse if treatment is missed or discontinued. • Suggest that the patient take the drug early in the morning to avoid sleep disturbance resulting from nocturia. • Inform patients that certain herbal products may interact with thiazide diuretics • Monitor vital signs and serum electrolytes, especially potassium, glucose, uric acid, and cholesterol levels. Report changes. If a patient is taking digoxin and hypokalemia occurs, digitalis toxicity frequently results. • Observe for signs and symptoms of hypokalemia such as muscle weakness, leg cramps, and cardiac dysrhythmias. • Monitor the patient’s weight daily. A weight gain of 2.2 lb is equivalent to 1 L of body fluids. • Note urine output to determine fluid loss or retention. POTASSIUM SPARING DIURETICS GENERIC NAME BRAND NAME • Spironoloctone • Aldactone Carospic • Amiloride • Midamor • Eplerenone • Inspra Drug Dosage Spironolacton e Tablet • 25 mg • 50 mg • 100 mg Oral Suspension • 5mg/ ml Eplerenone Tablet • 25mg • 50mg Tablet • 5mg Amilorid e Congestive Heart Failure • 5-10 mg Hypertension • 5-10 mg Thiazide-Induced Hypokalemia • 5-10 mg Pediatric tablet • 5 mg Mechanism of Action Potassium-sparing diuretics act to prevent sodium reabsorption in the collecting tubule by either binding ENaCs (amiloride, triamterene) or by inhibiting aldosterone receptors (spironolactone, eplerenone). This prevents excessive excretion of K+ in urine and decreased retention of water, preventing hypokalemia. Indications • Hypertension ( High blood pressure) • Congestive heart failure • Edematous conditions • Hyperkalemia • Anuria • Acute renal insufficiency Side effects/ Adverse effects • Hyperkalemia • Nausea and vomiting • Abdominal discomfort • Headache • Drowsiness • Confusion • Ataxia ( loss of control on body movement) • Kidney Stones • Note the half-life of spironolactone. With a long half -life, the drug is usually administered once a day, sometimes twice a day. • Monitor urinary output; it should increase. Report if urine output is less than 30 mL/h or less than 600 mL/day. • Record vital signs and report any abnormal changes. • Observe for signs and symptoms of hyperkalemia (serum potassium >5.0 mEq/L). Nausea, diarrhea, abdominal cramps, numbness and tingling of the hands and feet, leg cramps, tachycardia and later bradycardia, peaked narrow T wave on electrocardiogram, or oliguria may signal hyperkalemia. • Administer spironolactone in the morning and not in the evening to avoid nocturia. Generic Name • Mannitol Brand Name • Osmitrol DRUG DOSAGE 50 to 100 gm by a IV Mechanism of Action 1. inhibit water reabsorption in the proximal convoluted tubule and the thin descending loop of Henle and collecting duct, regions of the kidney that are highly permeable to water. Indications • Acute renal failure during a prolonged surgery or trauma • Glaucoma Contraindications • • • • • Intracranial bleeding Urinary tract obstruction Pulmonary congestion Edema Heart failure Side Effects/ Adverse effects • • • • • • • • Chest pain Congestive heart failure Phlebitis ( inflammation of the vein ) Convulsions Chills Dizzziness Headache Electrolyte imbalance Nursing Interventions • Assess neurologic status: LOC, ICP reading, pupil size and reaction when product is given for increased ICP • Assess for vision changes or eye discomfort or pain before, during treatment (increases intraocular pressure); neurologic checks, ICP during treatment (increased ICP) • Assess patient for tinnitus, hearing loss, ear pain; periodic testing of hearing is needed when high doses of this product are given by IV route • Assess fluid volume status: check I&O ratios and record hourly urine values, breath sounds, • weight, distended red veins, crackles in lungs, color, quality, and specific gravity of urine, skin turgor, adequacy of pulses, moist mucous membranes (provide adequate fluids), bilateral lung sounds, peripheral pitting edema ANTIDIURETICS Generic Name • Vasopressin • Desmopressin Brand Name • Antidiuretic Hormone • Minirin Drug Dosage Vasopressin • 5-10 units IM/ SC Diabetes insipidus • Adult: IM/SUBCUT 5-10 units bid-qid prn; CONT IV INF 0.0005 units/kg/hr, (0.5 milliunit/kg/hr), double dose q30min as needed • Child: IM/SUBCUT 2.5-10 units bid-qid prn Desmopressin • 100 - 400 mcg orally • 1 -4 mcg IV Mechanism of Action Reduces urine flow by acting reabsorption of water by kidney tubales Indication • Cranial Diabetes insipidus • Primary nocturnal enuresis • Nocturia associated with multiple selerosis Contraindication • Hypersensitivity • impaired renal function • With ongoing diuretic treatment • Edema • hypertension • fluid and electrolyte imbalance • pregnancy and lactation Side Effects/ Adverse effects • Nasal Irritation • Rhinitis • Abdominal Cramp • Urge defecate • Fluid retention • Congestion • Ulceration • Nausea Nursing Intervention • Monitor I&O ratio, urine osmolality, specific gravity, weight daily; check for edema in extremities; if water retention is severe, diuretic may be prescribed; check pulse, B/P when giving product IV or SUBCUT • Assess for water intoxication: lethargy, behavioral changes, disorientation, neuromuscular excitability, dehydration, poor skin turgor, severe thirst, dry skin, tachycardia • Assess intranasal use: nausea, congestion, cramps, headache; usually decreased with decreased dosage • Pregnancy/breastfeeding: No wellcontrolled studies, use only if benefit outweighs fetal risk, cautious use in breastfeeding, excretion is unknown • Use demonstration, return demonstration to teach technique for nasal instillation, clear nasal passage before use • Caution patient to avoid OTC products (cough, hay fever), since these preparations may contain EPINEPHrine and decrease product response; do not use with alcohol Urinary Antiseptic Generic Name Brand Name • Methenamine hippurate • Hiprex • Sulfamethoxazole • Bactrim • Nitrofurantoin • Furadantin • Fosfomycin • Manurol • Trimethoprim • Proloprim • Ertapenem • Invanz • Ketorolac Tromethamine • Toradol • Ciprofloxacin • Cipro Drug Dosage Methenamine hippurate Oral Solution • 500 mg/ml Tablet • 1 gram Sulfamethoxazole Injected Solution • (16mg/ 80mg)/ml Oral Suspension • (40mg/200mg)5ml Tablet • 80mg/400mg • 160mg/800mg Nitrofurantoin Capsule, macrocrystals • 25 mg • 50 mg • 100 mg Capsule, monohydrate/ macrocystal • 100 mg Oral Suspension • 25mg/5ml Trimethoprim Injected solution • (16mg/80mg)ml Ertapenem Powder for Injection • 1gram/vial Oral suspension • (40mg/80mg)ml Tablet • 80mg/400mg • 160mg/800mg Fosfomycin • 3 gram/ packet Ketorolac Tromethamine Tablet • 10mg Injectable solution • 15mg/ml • 30mg/ml Prefilled syringe • 15mg/ml • 30mmg/ml • 60mg/2ml Ciprofloxacin Infusion solution • 200mg/100ml • 200mg/20ml • 400mg/40ml • 400mg/200ml Oral Suspension • 250mg/5ml • 500mg/5ml Tablet • 100mg • 500mg • 750mg Tablet, extended release • 500mg • 1000mg Mechanism of Action There are bacteriostic drug. They inhibit the growth of different sepcies of bacteria in urine. • Methamine is used to prevent recurrent urinary tract infection • Sulphonamide are used to treat infections causes by susceptible organism in urinary tract • Pregnant and breast feeding women • Hisotry of Steven johnson Syndrome • Hypersensitive • Cautiously use in patient with mild to moderate renal or hepatic • disorder, severe allergies, blood dysrasias urinary obstruction Side Effects/ Adverse effects • Fever • Rash • Crystalluria • Nausea • Vomiting • Photosensitivity reaction • Steven's Job Syndrome • Monitor urinary output and urine specific gravity. Careful attention to output is required when administering urinary antiseptics to patients with anuria and oliguria. Report promptly any decrease in urine output. • Obtain urine culture to identify infecting organism before initiation of drug therapy to treat UTI. • Observe the patient for side effects and adverse reactions to urinary antiseptic drugs. Peripheral neuropathy (tingling, numbness of extremities) may result from renal insufficiency (inability to excrete drug) or long-term use of nitrofurantoin. Peripheral neuropathy may be irreversible • Teach patients not to crush tablets or open capsules. • Advise patients to rinse the mouth thoroughly after taking oral nitrofurantoin. The drug can stain teeth. • Teach patients to shake suspensions well before administration and to protect them from freezing. URINARY STIMULANT Generic Name Brand Name Bethanechol chloride Urecholine Drug Dosage • Adult: PO; 10-50 mg tid/qid 1 h or 2 h pc; max: 200mg/d • Adult: Subcut: 5 mg tid/qid PRN; max: 40 mg/d Mechanism of Action • to increase bladder tone by increasing tone of the detrusor urinal muscle, which produces a contraction strong enough to stimulate urination Indication • Acute potoperative urinary retention • neurogenic atony of the urinary bladder Contraindication • Hypersensitivity to bethanecol or to any component of the injection • Hyperthyroidism • pregnancy • lactation • peptic ulcer • latent or active bronchial asthma • vasomotor instability • coronary artery disease • epilepsy • parkinsonism Side effects/ Adverse effects • Dry mouth • Urinary retention • constipation • blurred vision Nursing Intervention • Assessment of urinary symptoms, and monitoring for side effects and therapeutic effects • Before taking bethanechol, tell your doctor if you have or have ever had asthma, a bladder infection, epilepsy, high blood pressure, heart disease, Parkinson's disease, an overactive thyroid gland, or ulcers. tell your doctor if you are pregnant, plan to become pregnant, or are breast feeding REFERENCES: McCuistion, L. E., Vuljoin-DiMaggio, K., Winton, M. B., Yeager, J. J. (2018). Pharmacology: A Patientcentered Nursing Process Approach. United States: Elsevier. Skidmore-Roth, L. (2018). Mosby's 2019 Nursing Drug Reference E-Book. United States: Elsevier Health Sciences. https://go.drugbank.com/ https://www.sciencedirect.com/ https://www.rxlist.com/how_do_osmotic_diuretics_work/drug-class.htm https://www.drugs.com/drug-class https://www.slideshare.net/diptisorte/drugs-used-on-urinary-system https://drive.google.com/file/d/1wpocbw8JNuwJIfkjl8JKhh8TtGbr8MDy/view?usp=sharing
