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2.2 Diuretics

2.2 Diuretics

2.2 Diuretics

            Hypokalaemia may occur with thiazides and loop diuretics. The risk is greater with thiazides as they have a longer duration 
            of action. Use of a potassium sparing diuretic can usually avoid the need for potassium supplement.
 
            2.2.1 Thiazides and related diuretics
                        GREEN      Bendroflumethiazide  tablets 2.5mg
                        GREEN      Indapamide
                                           tablets 2.5mg
                                         tablets MR 1.5mg 
            N.B. Where Bendroflumethiazide is to be used for oedema or where an alternative to Metolazone (discontinued by 
            manufacturer) is  needed, Bendroflumethiazide 5mg tablets would be suitable.
 
             2.2.2  Thiazides Loop Diuretics
                         First line treatment   
                         GREEN        Furosemide        
                                            tablets 20mg, 40mg    
                                             liquid 50mg in 5mL  
                         AMBER      Furosemide tablets 500mg
                         RED            Furosemide injection 20mg/2mL, 50mg/5mL, 250mg/25mL
 
                         Second line treatment - Only if poor response to furosemide       
                         GREEN       Bumetanide      
                                            tablets 1mg, tablets 5mg    
                                                  liquid 1mg/5mL         
 
                         Metolazone –an unlicensed tablet is available and is approved for inclusion in formulary for secondary care use only  
                         RED          Metolazone tablets (unlicensed secondary care only)   
 
             2.2.3  Potassium-sparing diuretics and aldosterone antagonists
                         Amiloride on its own is a weak diuretic. It causes retention of potassium and is used as a more effective alternative     
                         to giving potassium supplements with thiazide or loop diuretics.
                         Spironolactone is licensed only for congestive cardiac failure, hepatic cirrhosis with ascites and oedema, malignant 
                         ascites, nephrotic syndrome and the diagnosis and treatment of primary aldosteronism. 
                         Both of these drugs have the potential to cause hyperkalaemia with drugs acting on the renin-angiotensin system.
 
                         GREEN      Amiloride 
                                            tablets 5mg   
                                            liquid 5mg/5mL
                         GREEN      Spironolactone   
                                            tablets 25mg, 100mg
                         RED            Spironolactone   
                                            liquid 5mg/5mL, 10mg/5mL, 25mg/5mL, 50mg/5ml, 100mg/5mL  
                                            for NICU use only 
 
                         Eplerenone 
                         For patients with symptoms and/or signs of heart failure and left ventricular systolic dysfunction (LVSD), initiate
                         treatment with eplerenone, an aldosterone antagonist. Eplerenone is licensed for post-MI treatment within 3–14 days
                         of the MI, preferably after ACE  inhibitor therapy.  For patients with clinical heart failure and LVSD already being 
                         treated with an aldosterone antagonist for a concomitant condition (e.g. spironolactone), continue with the
                         aldosterone antagonist or an alternative, licensed for early post-MI treatment.  
 
                         Assessment/monitoring 
                         Monitor renal function and serum potassium before and during  treatment. If hyperkalaemia is a problem,
                         halve the dose or stop the treatment.
                         AMBER      Eplerenone
                                            tablets 25mg, 50mg
 
             2.2.4  Potassium-sparing diuretics with other diuretics
                         Fixed dose combinations may be justified where compliance is a problem.
                         GREEN      Co-amilofruse (amiloride, furosemide) 
                                            tablets 2.5/20, 5/40
 
             2.2.5  Osmotic diuretics
                         RED           Mannitol intravenous infusion 10%, 20%
 
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