Items in AFP with MESH term: Diuretics
ABSTRACT: Several large clinical trials conducted over the past decade have shown that pharmacologic interventions can dramatically reduce the morbidity and mortality associated with heart failure. These trials have modified and enhanced the therapeutic paradigm for heart failure and extended treatment goals beyond limiting congestive symptoms of volume overload. Part II of this two-part article presents treatment recommendations for patients with left ventricular systolic dysfunction. The authors recommend that, if tolerated and not contraindicated, the following agents be used in patients with left ventricular systolic dysfunction: an angiotensin-converting enzyme inhibitor in all patients; a beta blocker in all patients except those who have symptoms at rest; and spironolactone in patients who have symptoms at rest or who have had such symptoms within the past six months. Diuretics and digoxin should be reserved, as needed, for symptomatic management of heart failure. Other treatments or treatment programs may be necessary in individual patients.
ABSTRACT: Hospital admission for congestive heart failure is extremely common and quite expensive, although it is frequently preventable. New drugs and therapies have been reported to reduce admissions, decrease morbidity and mortality, and improve the quality of life for these patients. Patients with an ejection fraction less than 40 percent (decreased systolic function) should be treated with medication to improve symptoms and prevent progression of heart failure. Angiotensin-converting enzyme (ACE) inhibitors are a mainstay of treatment in patients who can tolerate them; in patients who cannot take these drugs, angiotensin II receptor blocking agents offer an alternative. Patients with New York Heart Association class II or III heart failure should also receive a beta blocker (metoprolol, carvedilol or bisoprolol). Recent research has shown that treatment with spironolactone improves mortality and hospital readmission rates. An exercise program should also be recommended for all patients with heart failure unless their condition is unstable.
ABSTRACT: The familiar diuretic spironolactone has taken on new life as a treatment for left-sided congestive heart failure. Spironolactone has been shown to decrease mortality in such patients who are New York Heart Association class IV. It can be used in addition to agents such as angiotensin-converting enzyme inhibitors and beta blockers, which also decrease mortality, and diuretics and digoxin, which are useful in treating symptoms. Spironolactone is safe, easy to use and reasonably priced. More research is necessary to determine the order and combinations of these medications in slowing the progression of this disease.
ABSTRACT: Adverse reactions to contrast agents range from a mild inconvenience, such as itching associated with hives, to a life-threatening emergency. Renal toxicity is a well known adverse reaction associated with the use of intravenous contrast material. Other forms of adverse reactions include delayed allergic reactions, anaphylactic reactions, and local tissue damage. Previous allergic reactions to contrast material, asthma, and allergies are factors associated with an increased risk of developing an adverse reaction. Pretreatment of patients who have such risk factors with a corticosteroid and diphenhydramine decreases the chance of allergic reactions, including anaphylaxis, renal failure, or a possible life-threatening emergency. Awareness of the different types of risk factors and prescreening for their presence allows for early recognition and prompt treatment. Prophylactic treatment before administration of contrast material can prevent potential adverse reactions. If such reactions do occur, prompt recognition allows them to be treated immediately. Using the smallest amount of contrast material possible and low-molecular, nonionic agents also decreases the relative risk of reactions. Renal insufficiency induced by contrast material may be prevented by ensuring adequate hydration and discontinuing other nephrotoxic medications before the procedure. Low-osmolar, nonionic agents are helpful in patients with known conditions associated with adverse reactions.
ABSTRACT: Hypertension and diabetes mellitus are common diseases in the United States. Patients with diabetes have a much higher rate of hypertension than would be expected in the general population. Regardless of the antihypertensive agent used, a reduction in blood pressure helps to prevent diabetic complications. Barring contraindications, angiotensin-converting enzyme inhibitors are considered first-line therapy in patients with diabetes and hypertension because of their well-established renal protective effects. Calcium channel blockers, low-dose diuretics, beta blockers, and alpha blockers have also been studied in this group. Most diabetic patients with hypertension require combination therapy to achieve optimal blood pressure goals.
A Practical Approach to Hypercalcemia - Article
ABSTRACT: Hypercalcemia is a disorder commonly encountered by primary care physicians. The diagnosis often is made incidentally in asymptomatic patients. Clinical manifestations affect the neuromuscular, gastrointestinal, renal, skeletal, and cardiovascular systems. The most common causes of hypercalcemia are primary hyperparathyroidism and malignancy. Some other important causes of hypercalcemia are medications and familial hypocalciuric hypercalcemia. An initial diagnostic work-up should include measurement of intact parathyroid hormone, and any medications that are likely to be causative should be discontinued. Parathyroid hormone is suppressed in malignancy-associated hypercalcemia and elevated in primary hyperparathyroidism. It is essential to exclude other causes before considering parathyroid surgery, and patients should be referred for parathyroidectomy only if they meet certain criteria. Many patients with primary hyperparathyroidism have a benign course and do not need surgery. Hypercalcemic crisis is a life-threatening emergency. Aggressive intravenous rehydration is the mainstay of management in severe hypercalcemia, and antiresorptive agents, such as calcitonin and bisphosphonates, frequently can alleviate the clinical manifestations of hypercalcemic disorders.
Treatment of Edema - Article
ABSTRACT: Edema is the result of an imbalance in the filtration system between the capillary and interstitial spaces. The kidneys play a key role in regulating extracellular fluid volume by adjusting sodium and water excretion. Major causes of edema include venous obstruction, increased capillary permeability, and increased plasma volume secondary to sodium and water retention. A systematic approach is warranted to determine the underlying diagnosis. Treatment includes sodium restriction, diuretic use, and appropriate management of the underlying disorder. Leg elevation may be helpful in some patients. Loop diuretics often are used alone or in combination. In patients with New York Heart Association class III and IV congestive heart failure, spironolactone has been found to reduce morbidity and mortality rates. In patients with cirrhosis, ascites is treated with paracentesis and spironolactone. Dihydropyridine-induced edema can be treated with an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker. Lymphedema occurs when a protein-rich fluid accumulates in the interstitium. Compression garments and range-of-motion exercises may be helpful in patients with this condition.
ABSTRACT: Major complications of cirrhosis include ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, portal hypertension, variceal bleeding, and hepatorenal syndrome. Diagnostic studies on ascitic fluid should include a differential leukocyte count, total protein level, a serum-ascites albumin gradient, and fluid cultures. Therapy consists of sodium restriction, diuretics, and complete abstention from alcohol. Patients with ascitic fluid polymorphonuclear leukocyte counts of 250 cells per mm3 or greater should receive empiric prophylaxis against spontaneous bacterial peritonitis with cefotaxime and albumin. Patients who survive an episode of spontaneous bacterial peritonitis should receive long-term prophylaxis with norfloxacin or trimethoprim/sulfamethoxazole. Patients with gastrointestinal hemorrhage and cirrhosis should receive norfloxacin or trimethoprim/sulfamethoxazole twice daily for seven days. Treatment of hepatic encephalopathy is directed toward improving mental status levels with lactulose; protein restriction is no longer recommended. Patients with cirrhosis and evidence of gastrointestinal bleeding should undergo upper endoscopy to evaluate for varices. Endoscopic banding is the standard treatment, but sclerotherapy with vasoconstrictors (e.g., octreotide) also may be used. Prophylaxis with propranolol is recommended in patients with cirrhosis once varices have been identified. Transjugular intrahepatic portosystemic shunt has been effective in reducing portal hypertension and improving symptoms of hepatorenal syndrome, and can reduce gastrointestinal bleeding in patients with refractory variceal hemorrhage. When medical therapy for treatment of cirrhosis has failed, liver transplantation should be considered. Survival rates in transplant recipients have improved as a result of advances in immunosuppression and proper risk stratification using the Model for End-Stage Liver Disease and Child-Turcotte-Pugh scoring systems.
ABSTRACT: Heart failure caused by systolic dysfunction affects more than 5 million adults in the United States and is a common source of outpatient visits to primary care physicians. Mortality rates are high, yet a number of pharmacologic interventions may improve outcomes. Other interventions, including patient education, counseling, and regular self-monitoring, are critical, but are beyond the scope of this article. Angiotensin-converting enzyme inhibitors and beta blockers reduce mortality and should be administered to all patients unless contraindicated. Diuretics are indicated for symptomatic patients as needed for volume overload. Aldosterone antagonists and direct-acting vasodilators, such as isosorbide dinitrate and hydralazine, may improve mortality in selected patients. Angiotensin receptor blockers can be used as an alternative therapy for patients intolerant of angiotensin-converting enzyme inhibitors and in some patients who are persistently symptomatic. Digoxin may improve symptoms and is helpful for persons with concomitant atrial fibrillation, but it does not reduce cardiovascular or all-cause mortality. Serum digoxin levels should not exceed 1.0 ng per mL (1.3 nmol per L), especially in women.
ABSTRACT: Combination therapy of hypertension with separate agents or a fixed-dose combination pill offers the potential to lower blood pressure more quickly, obtain target blood pressure, and decrease adverse effects. Antihypertensive agents from different classes may offset adverse reactions from each other, such as a diuretic decreasing edema occurring secondary to treatment with a calcium channel blocker. Most patients with hypertension require more than a single antihypertensive agent, particularly if they have comorbid conditions. Although the Joint National Committee guidelines recommend diuretic therapy as the initial pharmacologic agent for most patients with hypertension, the presence of "compelling indications" may prompt treatment with antihypertensive agents that demonstrate a particular benefit in primary or secondary prevention. Specific recommendations include treatment with angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, diuretics, beta blockers, or aldosterone antagonists for hypertensive patients with heart failure. For hypertensive patients with diabetes, recommended treatment includes diuretics, beta blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and/or calcium channel blockers. Recommended treatment for hypertensive patients with increased risk of coronary disease includes a diuretic, beta blockers, angiotensin-converting enzyme inhibitors, and/or calcium channel blocker. The Joint National Committee guidelines recommend beta blockers, angiotensin-converting enzyme inhibitors, and aldosterone antagonists for hypertensive patients who are postmyocardial infarction; angiotensin-converting enzyme inhibitors and angiotensin receptor blockers for hypertensive patients with chronic kidney disease; and diuretic and angiotensin-converting enzyme inhibitors for recurrent stroke prevention in patients with hypertension.