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diuretics_are_not_for_lymphedema [2011/11/02 07:43]
Pat O'Connor [Lymphedema People Resources]
diuretics_are_not_for_lymphedema [2012/10/16 14:40] (current)
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 A nonprofit organization for breast cancer education A nonprofit organization for breast cancer education
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 ======Diuretics and Lymphedema====== ======Diuretics and Lymphedema======
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   * Polycystic ovarian syndrome (PCOS).   * Polycystic ovarian syndrome (PCOS).
  A disorder marked by irregular menstruation,​ obesity, increased hair growth, cystic ovaries and infertility. (2)  A disorder marked by irregular menstruation,​ obesity, increased hair growth, cystic ovaries and infertility. (2)
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 ======Types of Diuretics====== ======Types of Diuretics======
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 The categories are defined based upon their mechanism of action. The categories are defined based upon their mechanism of action.
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 **a.** **//Osmotic Diuretics.//​** **a.** **//Osmotic Diuretics.//​**
  
 Osmostic diuretics produce a diuresis of water rather than a diuresis of sodium. The body does not metabolize osmotic diuretics. Instead, the drug molecules are not reabsorbed in the kidney tubules. This greatly affects the tonicity of every part of the kidney tubules through which the glomerular filtrates pass. By the process of osmosis, the drug molecules draw an increased amount of water from the interstitial fluid compartment. The result is that a great volume of urine is produced (water diuresis). It just so happens that sodium is contained in that urine and is subsequently removed from the body. Thus, the osmotic diuretics indirectly produce a removal of sodium from the body. Following is one example of an osmotic diuretic: Mannitol. Mannitol is used to prevent acute renal (kidney) failure, evaluate kidney functioning,​ treat glaucoma (by the reduction of intraocular pressure), promote the urinary excretion of toxic substances (diuresis in certain drug intoxications) and reduce intracranial pressure (pressure in the head). The usual dosage of mannitol is from 50 to 200 grams in a 24-hour period by intravenous infusion. Side effects associated with the use of mannitol include pulmonary congestion, fluid and electrolyte imbalance, acidosis, electrolyte loss, and dryness of mouth and dehydration. Since mannitol may crystallize on exposure to low temperatures,​ you should observe mannitol vials and premixed bags for such crystals. When you observe these crystals, you should warm the vials or bags in a 500° C water bath in order to dissolve the crystals. The product should be cooled to body temperature before the mannitol solution is administered. Mannitol is available in a 5, 10, 15, 20, and 25 percent injection. Osmostic diuretics produce a diuresis of water rather than a diuresis of sodium. The body does not metabolize osmotic diuretics. Instead, the drug molecules are not reabsorbed in the kidney tubules. This greatly affects the tonicity of every part of the kidney tubules through which the glomerular filtrates pass. By the process of osmosis, the drug molecules draw an increased amount of water from the interstitial fluid compartment. The result is that a great volume of urine is produced (water diuresis). It just so happens that sodium is contained in that urine and is subsequently removed from the body. Thus, the osmotic diuretics indirectly produce a removal of sodium from the body. Following is one example of an osmotic diuretic: Mannitol. Mannitol is used to prevent acute renal (kidney) failure, evaluate kidney functioning,​ treat glaucoma (by the reduction of intraocular pressure), promote the urinary excretion of toxic substances (diuresis in certain drug intoxications) and reduce intracranial pressure (pressure in the head). The usual dosage of mannitol is from 50 to 200 grams in a 24-hour period by intravenous infusion. Side effects associated with the use of mannitol include pulmonary congestion, fluid and electrolyte imbalance, acidosis, electrolyte loss, and dryness of mouth and dehydration. Since mannitol may crystallize on exposure to low temperatures,​ you should observe mannitol vials and premixed bags for such crystals. When you observe these crystals, you should warm the vials or bags in a 500° C water bath in order to dissolve the crystals. The product should be cooled to body temperature before the mannitol solution is administered. Mannitol is available in a 5, 10, 15, 20, and 25 percent injection.
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 **b.** **//​Thiazide Diuretics//​** **b.** **//​Thiazide Diuretics//​**
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 (3) __Chlorthalidone (Hygroton®).__ Although chlorthalidone is not the same chemically as the thiazide diuretics, it has the same effects as these agents. For indications and side effects, you should refer to hydrochlorothiazide. (3) __Chlorthalidone (Hygroton®).__ Although chlorthalidone is not the same chemically as the thiazide diuretics, it has the same effects as these agents. For indications and side effects, you should refer to hydrochlorothiazide.
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 **c.** **//​Potassium-Sparing Diuretics.//​** **c.** **//​Potassium-Sparing Diuretics.//​**
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 (2) __Triamterene (Dyrenium®).__ While triamterene produces effects similar to those of spironolactone,​ the effects produced by triamterene are not dependent on the presence of aldosterone. This agent acts directly on the distal tubule where it prevents the passage of sodium across the membrane of the tubule. Thus, by blocking sodium reabsorption,​ potassium loss is reduced. Triamterene is used for edema associated with congestive heart failure and cirrhosis of the liver. The usual dosage of this drug is from 25 to 200 milligrams per day. The daily dose should not exceed 300 milligrams. Side effects associated with this agent include electrolyte imbalances, hyperkalemia,​ weakness, and dry mouth. Like spironolactone,​ hyperkalemia is a major side effect which can occur in patients who have impaired renal function or when the drug is administered alone. (2) __Triamterene (Dyrenium®).__ While triamterene produces effects similar to those of spironolactone,​ the effects produced by triamterene are not dependent on the presence of aldosterone. This agent acts directly on the distal tubule where it prevents the passage of sodium across the membrane of the tubule. Thus, by blocking sodium reabsorption,​ potassium loss is reduced. Triamterene is used for edema associated with congestive heart failure and cirrhosis of the liver. The usual dosage of this drug is from 25 to 200 milligrams per day. The daily dose should not exceed 300 milligrams. Side effects associated with this agent include electrolyte imbalances, hyperkalemia,​ weakness, and dry mouth. Like spironolactone,​ hyperkalemia is a major side effect which can occur in patients who have impaired renal function or when the drug is administered alone.
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 **d.** **//​Carbonic Anhydrase Inhibitor Diuretics//​**  ​ **d.** **//​Carbonic Anhydrase Inhibitor Diuretics//​**  ​
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 __Acetazolamide (Diamox®).__ Acetazolamide is one example of a carbonic anhydrase inhibitor. Although rarely used today, it may be used in the treatment of edema because of congestive heart failure; drug-induced edema; petit mal and unlocalized seizures; and open-angle and secondary glaucoma. The usual dosage of this drug ranges from 250 milligrams to 2 grams--depending on the type of condition being treated. Actually, the dosage recommendations for glaucoma and epilepsy differ considerably from those of congestive heart failure, since the first two conditions are not dependent on carbonic anhydrase inhibition in the kidney which requires intermittent dosage if it is to recover from the inhibitory effect of the therapeutic agent. The side effects of this agent include loss of appetite, transient myopia (nearsightedness),​ drowsiness, and acidosis. Acetazolamide is available in the injectable form. __Acetazolamide (Diamox®).__ Acetazolamide is one example of a carbonic anhydrase inhibitor. Although rarely used today, it may be used in the treatment of edema because of congestive heart failure; drug-induced edema; petit mal and unlocalized seizures; and open-angle and secondary glaucoma. The usual dosage of this drug ranges from 250 milligrams to 2 grams--depending on the type of condition being treated. Actually, the dosage recommendations for glaucoma and epilepsy differ considerably from those of congestive heart failure, since the first two conditions are not dependent on carbonic anhydrase inhibition in the kidney which requires intermittent dosage if it is to recover from the inhibitory effect of the therapeutic agent. The side effects of this agent include loss of appetite, transient myopia (nearsightedness),​ drowsiness, and acidosis. Acetazolamide is available in the injectable form.
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 **e.** //​**Inhibition of Sodium Transport in the Ascending Limb of the Loop of Henle, the Distal Tubule, and the Proximal Sites Diuretics.**// ​ **e.** //​**Inhibition of Sodium Transport in the Ascending Limb of the Loop of Henle, the Distal Tubule, and the Proximal Sites Diuretics.**// ​
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 (2) Other loop diuretics include bumetanide (Bumex®), ethacrynic acid (Edecrin®),​ and torsemide (Demadex®). (2) Other loop diuretics include bumetanide (Bumex®), ethacrynic acid (Edecrin®),​ and torsemide (Demadex®).
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 **f. //​Inhibition of Sodium and Chloride Reabsorption Diuretics.//​** ​ **f. //​Inhibition of Sodium and Chloride Reabsorption Diuretics.//​** ​
  
 The mechanism of action of this type is very similar to the thiazide diuretics. That is, drugs of this category inhibit sodium and chloride reabsorption that results in the increased excretion of sodium, chloride, and water. Chlorthalidone (Hygroton®). This agent differs from the thiazide diuretics only in chemical structure. Chlorthalidone’s pharmacological action is indistinguishable from the thiazide diuretics. Chlorthalidone is used in the management of hypertension--either as the sole therapeutic agent or to enhance the effect of other antihypertensive drugs in patients who have the more severe forms of hypertension. It is also used as adjunctive therapy in the treatment of edema associated with congestive heart failure, hepatic cirrhosis, and various forms of renal dysfunctions. Refer to the information on hydrochlorothiazide for side effect information. The mechanism of action of this type is very similar to the thiazide diuretics. That is, drugs of this category inhibit sodium and chloride reabsorption that results in the increased excretion of sodium, chloride, and water. Chlorthalidone (Hygroton®). This agent differs from the thiazide diuretics only in chemical structure. Chlorthalidone’s pharmacological action is indistinguishable from the thiazide diuretics. Chlorthalidone is used in the management of hypertension--either as the sole therapeutic agent or to enhance the effect of other antihypertensive drugs in patients who have the more severe forms of hypertension. It is also used as adjunctive therapy in the treatment of edema associated with congestive heart failure, hepatic cirrhosis, and various forms of renal dysfunctions. Refer to the information on hydrochlorothiazide for side effect information.
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 **g. //​Combination Diuretics (Potassium-Sparing and Thiazide Diuretic Combination).//​**  ​ **g. //​Combination Diuretics (Potassium-Sparing and Thiazide Diuretic Combination).//​**  ​
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 Patients on diuretics should inform their physicians if they become sick, especially with severe or continuing vomiting or diarrhea. These conditions can cause the body to lose too much water and potassium.(2) Patients on diuretics should inform their physicians if they become sick, especially with severe or continuing vomiting or diarrhea. These conditions can cause the body to lose too much water and potassium.(2)
  
 +======Are diuretics safe and effective for lymphedema? ======
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 +No. Diuretics are not recommended for the treatment of lymphedema uncomplicated by other morbidities. Chronic diuretic use can cause electrolyte abnormalities and an overall worsening of the condition. (SOR: C, based on consensus guidelines.) Chlorothiazide is the only diuretic that has been studied. ​
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 +A double-blind crossover trial from 1965 compared chlorothiazide 500 mg twice daily given 5 days each week with placebo given on the same schedule as treat¬ment for primary lymphedema. Patients with coexisting cardiac, renal, and hepatic disease were excluded. There were 27 patients, and the study lasted 28 weeks, with patients completing 14 weeks of chlorothiazide therapy followed by 14 weeks of placebo.1 The patients showed a reduction in lower limb circumference (mean 0.25 inch, P less than .01), weight loss (mean 3.0 lb, P less than .05), and subjective improvement of symp¬toms (P less than .01) while being treated with chlorothiazide. There was, however, no correlation between symptom severity and degree of improvement with treatment, and none of the cases displayed complete resolution of the lymphedema. No significant side effects from the therapy were reported.1 ​
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 +In 1998, the American Cancer Society sponsored a workshop on lymphedema with the purpose of developing a consensus report on the diagnosis and treatment of the condition. Although they commented that the use of diuretics was still under evaluation, the drug class did not appear helpful for lymphedema uncomplicated by other morbidities.2 ​
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 +Experts have noted that the high protein content in the interstitial fluid of lymphedema allows it to rapidly pull water back into the interstitium via osmotic pressure after water is removed by the diuretic.3 Diuretics themselves can cause electrolyte disturbances with chronic use, and experts believe they can also encourage increased protein accumulation and fibrosis in the tissue, which could lead to a worsened condition.4,​5 ​
 +
 +HelpDesk Answer From EBP, 
 +Cody D. Mead, DO Vernon Wheeler MD 
 +Carl R. Darnall Army Medical Center FMRP Fort Hood, TX
 +
 +[[http://​www.globalfamilydoctor.com/​search/​GFDSearch.asp?​itemNum=12658&​ContType=HDA}Global Family Doctor]]
  
 ======Lymphedema People Internal Links====== ======Lymphedema People Internal Links======
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 [[lymphedemapeople@yahoo.com]] [[lymphedemapeople@yahoo.com]]
  
-Updated ​Nov 22011+Updated ​Jan. 152012
diuretics_are_not_for_lymphedema.txt · Last modified: 2012/10/16 14:40 (external edit)