The best diuretics to eliminate leg swelling

Author: Boris Ginzburg

*Review of the best according to the editors of simplerule.ru. About the selection criteria. This material is subjective in nature, does not constitute advertising and does not serve as a purchase guide. Before purchasing, consultation with a specialist is required.

Everyone intuitively understands what edema is. This is a condition when excess fluid, that is, water, accumulates not in the vascular bed, but in tissues, intercellular fluid, or in various cavities of the body. The main cause of edema is a change in water pressure in the capillaries, or hydrostatic pressure. After all, the capillary bed is extremely huge in area, and far exceeds the area of ​​large main vessels.

The second reason can be considered a drop in blood plasma pressure associated with protein concentrations, or oncotic pressure, along with an increase in oncotic pressure in the intercellular fluid. The cause of increased fluid accumulation in tissues may also be a violation of lymph flow. In old age, edema is most often a complication, and it can be considered a marker of severe pathology of the cardiovascular system, especially if the edema is located in the legs.

If swelling exists on the face, this most often indicates chronic kidney pathology. Doctors know that the appearance of any edema, especially not local, but generalized, is an important symptom of the pathology of the cardiovascular and excretory systems. Edema becomes noticeable and pronounced when a person’s body weight increases by 15% due to the volume of accumulated fluid, and for a person with an average weight of 70 kg this is two extra liters of fluid.

If we list diseases, then, in addition to chronic cardiovascular failure, the causes may be chronic and acute glomerulonephritis, nephrotic syndrome and chronic liver diseases such as cirrhosis. Hypothyroidism or myxedema, as well as the use of certain medications, often lead to the appearance of edema. Of these, we can name combined oral contraceptives, COCs. We will not go into detail about the classification of general and local edema, we will only say what the characteristic symptoms of certain edema are with their different origins.

Medicinal and herbal diuretics.

September 23, 2022
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Content

• How to choose a diuretic
• What are the types of diuretics?
• Classes of diuretics and indications for their use
• The best diuretics
• Hydrochlorothiazide
• Furosemide
• Indapamide
• Veroshpiron
• Torasemide
• Triampur compositum
• Diuver
• Dog-rose fruit
• Diuretic collection
• Juniper fruits

The doctor prescribes diuretics for various edema, hypertension, for the prevention of kidney stones, etc. It is no secret that some women even try to lose weight with the help of diuretics, but this is dangerous to health. The fact is that diuretics, together with liquid, remove potassium from the body - muscle contraction (including the heart muscle) is disrupted. That is why such drugs should be prescribed exclusively by a doctor, taking into account the underlying disease, possible contraindications and side effects.

Read also How to treat dehydration: 5 solutions for rehydration What drugs for dehydration are most often prescribed by doctors?

Contraindications of drugs

The use of diuretics is not always advisable. There are certain conditions that prohibit the use of this type of medicine. These include:

1. ​Low potassium levels in the blood.
2. ​Individual intolerance to sulfonamide substances.
3. ​Severe form of respiratory failure.
4. ​Acute kidney diseases.
5. ​Any type of diabetes.

An implicit contraindication to taking diuretics is ventricular arrhythmia. This clinical condition requires adjustment of the therapeutic dose and strict medical supervision.

How to choose a diuretic

There are specific factors to consider if you choose a diuretic.

1. Speed ​​of action.
   There are diuretics for emergency use: if you need to quickly lower high blood pressure (used in combination with other drugs), remove morning puffiness under the eyes. You should not take such medications often because they are addictive. Long-acting diuretics are prescribed to treat hypertension and edema associated with poor heart and liver function.
2. Pregnancy and breastfeeding.
   Any diuretic medications are prohibited for pregnant and lactating women. And only in cases where a pregnant or lactating woman has a threat to her health and life, is it possible to use them. Usually this phrase sounds like “the benefit to the mother outweighs the risk to the fetus.” The exception is practically harmless herbal diuretics, but a woman should talk to her doctor before using them.
3. Tendency to allergies.
   People with allergies may experience an undesirable reaction to both the active ingredient of the diuretic drug and its minor components. If you are allergic, consult your doctor before treatment.

In addition to diuretic medications, mild herbal remedies are often used. They are usually prescribed in the complex treatment of cystitis, urethritis, etc. Herbal diuretics not only remove excess water, but also relieve inflammation.

Drinking diuretics for weight loss is dangerous - the heart muscle suffers

Photos from open sources

Diuretics: what are they, why are they prescribed?

The term "diuretics" is quite common. But few people know what they are and how to take them correctly. In simple terms, diuretics or diuretics are medications that remove excess fluid from body tissues. At the same time, cleaning occurs from:

• toxins;
• salts

Attention! When taking diuretics, it is important to understand their mechanism of action. It is quite simple - the components of the drug act on the body in such a way as to enhance the outflow of fluid that is excreted naturally.

As a result, the total blood volume decreases and the load on the body decreases.

Sites of action of diuretics

Diuretics are divided into several categories:

• loop - the most powerful of all diuretics are prescribed for serious diseases, but have a short-lived effect and simultaneously remove potassium;
• thiazides are effective and safe even for newborns, but with regular use and if the dosage is exceeded, they cause potassium removal and an increase in blood sugar levels;
• potassium-sparing - have a long period of action and are successfully combined with other drugs, but in monotherapy the result will be weak;
• carbonic anhydrase inhibitors - prescribed in strictly defined circumstances, as they give a very insignificant effect;
• of plant origin - a practically harmless and gentle diuretic, which is not suitable for serious diseases.

There are many reasons for prescribing diuretics:

• various kidney diseases;
• cardiovascular diseases;
• endocrinological disorders;
• allergy;
• PMS;
• pregnancy;
• individual reaction of the body to elevated environmental temperatures.

Diuretics are usually perceived as a first aid medicine for edema. And they give good results. But uncontrolled use can cause serious harm to the body.

The list of negative consequences includes:

• potassium withdrawal;
• addictive effect;
• water-electrolyte imbalance;
• convulsions;
• decrease in pressure;
• arrhythmia and more.

Therefore, you can start taking it only in consultation with a specialist.

Anti-edema medications are often used for weight loss. And indeed, in a week the drugs can help you lose up to 5 kilograms. But this process has nothing to do with real weight loss. The effect can be achieved by removing fluid from the tissues and it is not always superfluous. Therefore, there is a high risk of getting dehydration, and with it:

• general deterioration of health;
• drying of the skin;
• weakness.

Diuretics for excess weight are indicated in combination with other measures and only in very dosed doses.

Let's look at Diuretics video

What are the types of diuretics?

All diuretic drugs are divided into several categories: according to their spectrum of use and mechanism of action.

1. Loop diuretics.
   These drugs have the strongest effect (they begin to act literally a few minutes after administration), but the effect ends just as quickly. Such drugs are well suited for the treatment of hypertension and heart failure. But loop diuretics have a significant disadvantage - along with water, they remove potassium from the body, which is fraught with the development of arrhythmia.
2. Thiazide diuretics.
   Another effective diuretic drug. They not only get rid of excess fluid, but also dilate peripheral vessels. Thiazide diuretics also reduce the response of blood vessels to adrenaline, so they spasm less. Such diuretics are also prescribed for the treatment of urolithiasis. Among the “side effects” are the excretion of potassium and an increase in uric acid, which can then accumulate in the joints and cause gout.
3. Potassium-sparing diuretics.
   Such diuretics do not remove potassium from the body, protecting the patient from various heart complications. But these drugs are not as potent as the previous ones.
4. Osmotic diuretics.
   This group of drugs reduces blood plasma pressure - excess water is quickly removed from the tissues, swelling goes away. The pressure in the tissues and in the plasma becomes the same. Typically, osmotic diuretics are prescribed to relieve swelling of the brain, lungs, and high intraocular or intracranial pressure.

Problems of prescribing modern diuretics in patients with CHF

Vladimir Trofimovich Ivashkin , academician of the Russian Academy of Medical Sciences, Doctor of Medical Sciences:

— We will ask Professor Grigory Pavlovich Arutyunov to tell us about adequate diuretic therapy for chronic heart failure. Please, Grigory Pavlovich.

00:13

Arutyunov Grigory Pavlovich , Doctor of Medical Sciences, Professor:

— Thank you very much, Vladimir Trofimovich.

Dear Colleagues. Chronic heart failure syndrome is a very well known syndrome since ancient times. Times change, but there is always a big problem in describing this syndrome, in describing the symptoms characteristic of this syndrome.

(Slide show).

Modern clinical portrait of a patient suffering from circulatory failure. Green bars indicate doctors' opinions. Red bars – this is what happens in real clinical practice. Like many centuries ago, for many decades, the first positions are still the feeling of lack of air and clearly pronounced swelling that occurs in these patients.

Whatever new symptoms have appeared in recent years (for example, fatigue - a superbly described syndrome in the last decades of the 20th century), the special significance of old symptoms remains, the fight against which, in fact, is clinically significant in preserving the lives of our patients.

But the word “edema” in the minds of an internist or therapist is primarily associated with the word “diuretic drugs.”

As modern recommendations say, when diuretics should appear in the treatment regimen for circulatory failure. Let's take the simplest patients, the mildest. Circulatory failure, functional class I-II, also sinus rhythm.

Start-up therapy always begins with an ACE inhibitor; in case of intolerance, it is an ARA. Only then, when ACE inhibitors are titrated, in the presence of edema, the therapist has the right to raise the question of diuretic therapy.

If patients have atrial fibrillation, even in this situation, diuretics are not the first line. These are still drugs that correct the patient’s neurohormonal profile. These are glycosides for atrial fibrillation. Only when the rhythm is controlled with titrated drugs does the issue of diuretics come on the agenda.

In more severe patients, functional class III-IV, but still maintaining sinus rhythm, the therapist has the right to administer diuretics for the first time, the first line of drugs.

In patients with atrial fibrillation of functional class III-IV, three drugs are used in treatment. These are ACE inhibitors, diuretics (please note, first-line diuretics) and glycosides.

02:47

We have talked about the first conditional place for diuretics. Let's start with the first law of prescribing diuretics for a therapist. Without edema, there is no diuretic therapy. If there is no material substrate (no edema), the therapist should not think about diuretic therapy in the treatment of CHF.

However, edema itself requires the therapist to understand what kind of edema it is. Let us describe the swelling that requires diuretics. Let us remember Botkin, his description of edema. Patients with circulatory failure must obey the law of symmetry. Symmetrical swelling. Feel the swelling - it should be dense and cold. Check their color - they should be blue.

So, dense, cold, symmetrical swelling is swelling caused by hydrostatic problems and circulatory failure. Then diuretics come on the agenda.

When the law of symmetry is violated, edema becomes one-sided, and there is no place for diuretics. This is a surgical problem that requires a solution, always urgently.

The therapist meaningfully looked at the swelling, felt it, assessed its color, temperature and made a decision on prescribing diuretics.

What do we achieve by prescribing diuretics? First of all, we will influence the removal of sodium and sodium-related chlorine from the body. Since the volume of extracellular fluid is regulated mainly by the content of sodium and chlorine in the body, we will influence the exit of fluid from the body with primary, then secondary urine.

04:41

The law of the power of diuretics. The closer to the nephron, the stronger the effect of the diuretic drug. There are exceptions to this rule. Diacarb does not obey this rule. It acts next to the nephron. But this is not a powerful diuretic drug.

Closest to the level of the loop, loop diuretics will act (hence their name). Thiazide diuretics will continue to work. Potassium-sparing diuretics will act even further. So, we remember the first basic rule. The closer to the nephron, the more powerful the effect of the diuretic drug, with the only exception for the drug Diacarb.

Let's look at the second and third laws. They should always be in the therapist's working memory. Diuretics should not be prescribed discretely. Prescribing diuretics 1-2 times a week, on even or odd days, does not benefit the patient. On the contrary, they begin to shake up the patient’s neurohormonal profile.

What will happen to the patient when he takes diuretics irregularly. For a certain amount of time, the volume of urine produced will increase sharply. The neurohormonal profile will change. In response to the excreted fluid, oversynthesis of angiotensin II and norepinephrine will begin. You will begin to improve your neurohormonal profile.

Diuretics are prescribed daily in small doses, but in no case discretely, which today should not be considered at all in treatment regimens for circulatory failure.

The question of the history of the development of diuretics is very interesting. At the dawn of medicine, herbal remedies were diuretics. Then, quite by accident, during the period of treatment for syphilis, it was discovered that mercury (mercury ointment was used in the treatment of syphilis) has a diuretic effect. Of course, the diuretic drug turned out to be surprisingly toxic.

The era of diuretics is the post-war era. After World War II, when the first effective diuretics were synthesized, which were not so toxic and were clinically highly effective.

The process of synthesizing new drugs has not been completed. Today in the 20th century we are talking about three new classes of diuretics. This is a process that will probably evolve all the time.

But we remembered the history of the synthesis of diuretics only in order to approach the fourth law of prescribing diuretics. Diuretics are prescribed by the therapist according to the principle: from weakest to strongest. This is justified, because the stronger the diuretic effect, the stronger the diuretic drug, the greater its side effects, the greater its toxic effect.

07:40

So, let's look at a diuretic drug that is much weaker than loop diuretics.

This is a thiazide diuretic. It will, first of all, reduce the reabsorption of chlorine. This is his most important thing. Together with chlorine, it will have a passive effect on the excretion of sodium and sodium-bound water.

It is very important to see that the group of thiazide diuretics that we so easily talk about is a very large group. It includes the well-known drug Indapamide, Hydrochlorothiazide, Chlorthalidone, which is better known in other countries than here. However, these are completely different drugs.

This difference in diuretics means that the physician must be aware of the half-life. These half-lives are too different to be consistent across this group. The half-life of a diuretic drug is the most important indicator of a diuretic drug. The longer the half-life, the greater the toxic effect of the diuretic, the less its effect on the neurohormonal profile of our patient.

(Slide show).

Let's look at thiazide diuretics.

Well defined white line. One of the most important side effects of the thiazide diuretic drug (two arrows below the potassium level) is high potassium output. Consequently, high doses of thiazide diuretics will always be fraught with the development of severe arrhythmias. Sodium is excreted significantly less than potassium. This is a very important point.

Finally, thiazide diuretics have a rather toxic effect on the glomerular filtration rate.

09:20

Side effects. The discussion about the dose of thiazide diuretics ended today. 12.5 mg taken with ACE inhibitors is considered safe. Doses lower than 12.5 mg are safe. This is a very important find for us. But we remember that thiazide diuretics will interfere with the lipid spectrum, affect cholesterol levels, and, unfortunately, have a negative effect on blood glucose levels in high doses.

Application. Here the therapist must remember a simple rule. The worse the kidney function, the lower the glomerular filtration rate, the less effective thiazide diuretics. At a figure of 40 ml/min. (glomerular filtration rate calculated by Cockcroft-Gault or MDRD formula) thiazide diuretics are practically ineffective. This is a very important point when we build a daily treatment regimen for patients.

Loop diuretics are much more effective than thiazide diuretics. The point of action of a loop diuretic is the thick segment of the ascending limb of the loop of Henle. This site will reabsorb 25% of the filtered sodium. If we block the entry of sodium back, then water will leave along with the sodium.

Why are loop diuretics so effective? Along with sodium, other electrolytes will also leave. We are talking about calcium and magnesium. High doses will still interfere with the electrolyte balance and may cause rhythm disturbances in the patient.

A loop diuretic removes sodium much more than a thiazide diuretic, but at the same time it also affects the level of potassium excretion. Any diuretic drug, interfering with the electrolyte balance, will be fraught with rhythm disturbances.

Let's not forget that a large volume of water leaves along with the excreted sodium. Therefore, there will be a direct effect on hematocrit. If you are treating a bedridden patient, then ideal conditions will be created for deep vein thrombosis of the leg. Loop diuretics in high doses will always produce high levels of water excreted from the body. The therapist should always keep in mind the high probability of not only rhythm disturbances, but also thrombosis of the deep veins of the leg with possible embolic syndrome in the pulmonary artery.

Toxic effect. The most important indicator on which the patient’s life expectancy largely depends is the glomerular filtration rate. There are no negative effects here with moderate doses. However, there will be a sharp decrease in glomerular filtration rate with high doses of loop diuretics.

12:32

Let's come to the class of loop diuretics.

They are also very different from each other. These are ethacrynic acid, Furosemide and Torasemide. The main indicator by which they differ is the half-life. The second indicator is the metabolism of the diuretic drug. The more a diuretic drug is excreted through the kidney, the more toxic and negative its effect, especially in patients with initially altered kidney function (as in our patients with circulatory failure).

I would like to draw your attention to the doses that are recommended by World Guidelines for administration, for example, Furosemide. Oral, of course, taking 40 mg, 160 mg is not an everyday practice dose, but such practice exists in the world. We must be prepared that doses of loop diuretics will not pass without a trace.

Where will the negative effect of high doses be if taken daily or discretely? If we block the absorption of sodium, then we must clearly remember that after stopping the circulation of the drug in the blood, unfortunately, rebound syndrome will occur. This will be post-diuretic reabsorption. The amount of sodium that will be absorbed from primary urine will increase sharply.

The half-life of the diuretic drug becomes dominant. We should aim for a long half-life to reduce the syndrome of increased post-diuretic reabsorption. This is the first one. But if more sodium is absorbed and the cells are not ready for it, they will die.

Second point. We blocked sodium absorption by 25%. This means that sodium has moved further along the tubules. Unfortunately, cells in distant sections are not ready for such an amount of sodium. This will lead to direct toxic damage.

The third point that the therapist should always remember is the glomerular filtration rate. The lower it is, the higher the concentration at usual doses of the drug, the greater the direct toxic effect of the diuretic drug. We must keep this direct toxic effect of a diuretic drug in our working memory, because it worsens the patient’s condition and shakes his neurohormonal profile.

Finally, remember that Furosemide is the main drug in this group. 65% of it is excreted by the kidneys. Let's remember this number. This is a very important number. It is very high, because Torasemide will be excreted significantly less through the kidney. This becomes important for the therapist when choosing long-term, lifelong therapy with diuretics.

15:21

The main side effects of diuretics. The first and constant effect is the effect on the activity of the renin-angiotensin-aldosterone system. Diuretic therapy will always cause angiotensin II activity to increase and a cascade will follow that will cause high angiotensin II levels. General peripheral vascular resistance will increase, sodium reabsorption will increase, leading to myocardial hypertrophy and hypertrophy of smooth muscle elements.

The second point is the nephrotoxic effect. Any diuretic drug does not remain indifferent to the kidney. It affects the kidney. Finally, we must remember that we are reducing the patient’s quality of life. After the prescription of a diuretic drug, the number of urinations increases. This is significant.

Imagine a real working class 2 patient to whom you have prescribed a diuretic. After taking a diuretic in the morning, the number of urination increases for several hours. At this time he must go to work. We are creating parameters that will worsen his quality of life.

For a very long time we knew that diuretics do not increase life expectancy. According to meta-analyses, they led to an even greater likelihood of deaths, unfortunately.

This was the case until a key study was carried out with the drug Torasemide. For the first time, diuretics have been shown to reduce the risk of death in patients with circulatory failure.

17:05

So, the patient received a loop diuretic. However, you see that a certain pattern occurs: the therapist is unable to achieve adequate urine output. What should a therapist do for a patient with circulatory failure. First of all, think about the pH of your urine. We need to acidify the urine.

It is well known that for this purpose there is a diuretic drug from the “reserve group”. We are talking about the drug Diacarb. Prescribing Diacarb for a short course of 5-7 days changes the pH of urine and increases the effectiveness of diuretic therapy with loop diuretics.

This is also a very interesting story about the appearance of Acetozolamide. It was a drug that actually came out of antibiotics. No one will remember it now as an antibiotic. But this is a very interesting diuretic drug, which primarily affects the pH of urine, helping loop diuretics to act.

We are approaching the drugs with the weakest diuretic effect. These are mineralcorticoids. There are two drugs. Spironolactone is justified. Eplerenone is a bit arbitrary. Eplerenone is an aldosterone receptor antagonist with a diuretic effect.

They differ in only one thing. Eplerenone differs from Spironolactone in that it has two radicals that have a sexual effect cut off. Every tenth man on Spironolactone developed gynecomastia. Eplerenone does not have this effect. This is a very interesting connection.

This is a drug that is not considered as an independent diuretic drug, but as a drug added to an already existing diuretic regimen. In normal doses there is no toxic effect. You need to remember the prescription regimen for this drug.

When large doses are used. When the therapist consciously uses large doses. Then, when there is circulatory decompensation and conventional therapy with loop diuretics does not allow “wetting” the patient and achieving a lasting diuretic effect (then large doses are justified).

There are more commonly prescribed smaller doses (25 – 50 mg). These are doses that are prescribed continuously, for life. For a patient with functional class III-IV, since there we achieve not so much a diuretic effect (I beg you to pay attention to this), there we achieve the effect of blocking the D-position of collagens.

This is the first time we are talking about the additional effect of a diuretic drug that does not relate to the kidney at all. We are talking about blocking the D-position of collagen in the body of a person suffering from circulatory failure.

19:50

Let's return to the class of diuretics. They all vary. First of all, we pay attention to half-lives. It was shown in volunteers, young people, that Torasemide has the highest half-life. The higher the half-life, the safer the diuretic.

What we should remember from the pharmacokinetics of Torasemide. The most important drug. Where the use of, for example, Furosemide is ineffective, Torasemide will be more effective.

The long half-life helps you remember two things. It can be used in patients with initially altered kidney function. In an elderly patient, there is no need to modify the dosage.

Let's remember the most important thing. 80% of administered Torasemide is metabolized in the liver. This means that only 20% is excreted through the kidney. This means that this drug can be used in patients with inherently altered kidney function. This sets Torasemide apart from the entire class of loop diuretics, making it safe and widely used.

What does Torasemide do? Look at the word "aldosterone". It's a hormone. Locally in the kidney, due to the fact that the patient has circulatory failure, the renin-angiotensin-aldosterone system turned on. Aldosterone, in addition to affecting sodium levels, will affect local synthesis and D-position of collagen. How serious is this? Let's ask this question and see the answer a little later.

The concentration of potassium and magnesium does not show a peak-like decrease. This means there is no need to expect, or at least the probability of severe rhythm disturbances will not be very high.

21:41

One more thing. The most important thing for the patient. He knows about the level of potassium and sodium, but he does not clearly see the amount of urination that occurs after taking a diuretic drug. Torasemide has a smooth line. It is very important. There will be no sharp deterioration in the patient's quality of life after taking this diuretic drug.

The left ventricular myocardial mass index decreases. Let's ask the question: why? We asked the second question. Why does the mass of the left ventricular myocardium decrease and why is it necessary to influence the level of collagen? Easy enough to explain. Transmitral blood flow actually improves because you change the volume of circulating blood. It's easy to explain. But how to explain the left ventricular myocardial mass index?

Let's look at one more thing - hormones. The circulating blood volume changed, and brain natriuretic peptide decreased. It's clear. But what happened to aldosterone. The diuretic drug Torasemide, in addition to its diuretic effect, has a direct effect on the level of aldosterone activity.

What does this lead to? First of all, to reduce fibrosis. When you and I were born, for each of us the distance between the capillaries and muscle bundles of the myocardium was determined genetically. This distance, which ensured an even supply of nutrients and oxygen, was guaranteed by the amount of collagen between the muscle bundles.

At a young age, thin and delicate threads are collagen. A patient with circulatory failure has an intravital biopsy sample. Collagen cables that are deposited in the myocardium push the bundles apart, making the myocardium thick and electrically unstable. This is, of course, extremely bad.

A diuretic that can not only reduce circulating blood volume but also affect this D-position of collagen will be very important for us.

(Slide show).

Powerful pink fields at the top are on Furosemide. The absence of pink fields at the bottom is on Thorasemid. There is no collagen not only in the kidney, but also in the myocardium. What gives such an effect of using Torasemide. We chose Torasemide from a whole class of loop diuretics. Reliably reduces hospitalization. The total number of hospitalizations is decreasing. The most important thing is that the average patient stay in bed is reduced.

Why are these numbers important to us? This is not just a mechanical reduction in the patient's stay in the hospital. These include fewer deep vein thromboses, less impact on nosocomial infections, and fewer pulmonary embolisms.

24:29

The patient was treated with Furosemide and then switched to Torasemide. Will we succeed? Yes. The use of torasemide after long-term therapy led to a sharp decrease in the number of hospitalizations. This is an essential thing.

For the first time, it was shown that therapy with a diuretic drug led to a decrease not only in overall death, but, more importantly, in a decrease in sudden death. By reducing the D-position of collagen, which led to electrical homogenization of the myocardium. There is no disconnection, no electrical instability (at least much less of it). Naturally, reducing the load and volume. This is very important data for everyday practice.

I specifically show, by way of contrast, studies that were performed long before our understanding of the half-life of loop diuretics. Before the advent of Diuver, a meta-analysis performed on Furosemide, the placebo line was higher than the Furosemide line. This means that the number of deaths was lower on therapy without diuretics.

How then can we help a patient with circulatory failure? We still faced the problem of choosing a diuretic drug. When we took into account the half-life, when we took into account the fact that Diuver interferes with the D-position of collagen, it led to a reduction in mortality and a reduction in hospitalization of patients.

The TORIC study is also important to us because we firmly stated that a diuretic always leads to increased potassium excretion from the body. This means that severe rhythm disturbances are expected. The effect of Torasemide is milder compared to Furosemide in its effect on potassium levels. There is no peak decrease in potassium.

26:36

One more thing. We will now allow ourselves to say that Diuver has a long-lasting effect. It is very important. There is no peak-like fluctuation in the level of neurohormones. Question two: There is no spike in potassium levels, which suggests that severe arrhythmias are unlikely to occur.

A very important fact for a therapist is that sudden death is reduced by almost 70%. This is the first time we are saying that a diuretic drug can have such a powerful antiarrhythmic effect. But still, in the daily practice of a therapist, there are very frequent situations when he has a refractory kidney, when he cannot achieve an adequate amount of urine. How to be.

Let's start with the most common cause of refractoriness. This is incompliance. Patients forget to take diuretics or do not take them regularly. There is concomitant therapy that requires taking non-steroidal anti-inflammatory drugs.

There is one more point. This, unfortunately, is a catastrophic decrease in glomerular filtration rate. If the rate is below 40, then the first thing the physician should do is to stop prescribing Hydrochlorothiazide and consider switching the patient to a daily loop diuretic.

One more issue to pay attention to. Diuretics will never be effective unless you control the renin-angiotensin-aldosterone system. ACE inhibitors are mandatory in any patient receiving diuretic therapy.

Then begins the aerobatics of the therapist - this is combined diuretic therapy. If you don't get results with simple therapy, consider a combination.

Combination stages. There is no effect on a simple loop diuretic - increase the dose. No effect - think about the method of administration. Perhaps the edema syndrome is such that intramuscular or oral administration will not be effective. Then you need to switch to intravenous administration. If administered intravenously, the physician should be aware that different rates will have different diuretic effects.

Let's remember them. Bolus administration will be less effective than drip administration over a long time interval. If you have not achieved an effect on a loop diuretic, combine it with either a thiazide (this is terribly toxic to the kidney, but will be effective in terms of the volume of water excreted) or combine it with Spironolactone. When you add or subtract a diuretic, always remember that Torsemide has the fewest side effects.

29:21

But the most important effect for us will be the law, which sounds like this: having achieved the effect, titrate the diuretic drug to smaller doses. Patients with CHF who receive minimal doses of diuretics live the longest. This is extremely important. This is a snapshot of the modern use of diuretics in the modern treatment of CHF.

What does the future hold for us? Several new classes of drugs. Adenosine receptor blockers. They have now entered the stage of clinical trials. This is Rolofilin. These are necessarily vasopressin receptor antagonists (selective or non-selective). They have already entered everyday practice. These are peptides with a natriuretic effect.

Therapy with diuretics has been and remains a difficult chapter in the daily practice of a therapist, requiring deep knowledge and high aerobatics of the therapist in prescribing diuretics.

Thank you for your attention and the honor you have shown me.

Vladimir Ivashkin : Thank you very much. If you analyze or remember the names of all those who contributed to the creation of this ladder of diuretic effectiveness, do you think the scientist who discovered the diuretic effect of digitalis, and generally found digitalis, would he have received the Nobel Prize? Or was it pushed aside by other more modern manufacturers or creators of diuretics?

Grigory Arutyunov : No, I think they would definitely give it to him, because he turned the vector of clinical thinking. After all, he is an internist, and his understanding of the patient was turned once and for all. There was a completely different perception of the patient, a completely different vision of the future of this patient. I think the contribution he made to history cannot be overstated.

Vladimir Ivashkin: He did not have a chemical laboratory with a large number of employees. He was just thinking.

Grigory Arutyunov: He was a doctor who looked at the patient, touched, listened, and understood.

Vladimir Ivashkin : Thank you very much.

Classes of diuretics and indications for their use

Main indications for the use of diuretics of various classes

Hydrochlorothiazide

One of the most effective means for removing excess fluid and sodium salts from the body. Hydrochlorothiazide is prescribed for diseases of the kidneys, heart, lungs, to reduce blood pressure and reduce swelling. The drug does not form metabolites and is excreted unchanged by the kidneys. The maximum effect of the diuretic is achieved 4 hours after administration, and it lasts for 12 hours. Patients about it has a pronounced diuretic effect, any swelling quickly goes away, it is inexpensive. Among the disadvantages is a large list of “side effects” and the removal of important microelements from the body (including potassium and magnesium).

Hydrochlorothiazide

OZON, Russia; Pranapharm LLC, Russia; PJSC "Biokhimik", Russia; OJSC Borisov Plant of Medical Preparations (Borimed), Belarus; PJSC Valenta Pharm, Russia

A diuretic drug that is used for: Arterial hypertension, edema syndrome of various origins (chronic heart failure, nephrotic syndrome, renal failure, fluid retention in obesity), diabetes insipidus, glaucoma (subcompensated forms).
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Distinguishing the cause of edema

Of course, this material is not addressed to doctors, but a specialist should understand the causes of edema. But the modern Russian healthcare system is designed in such a way that it is extremely difficult to immediately get free access to a specialist; you must first visit a therapist as a “divorce”. Therefore, many turn to a paid doctor, and the main thing is to choose exactly who to turn to for edema: a cardiologist, a vascular surgeon who deals with the problems of varicose veins, or, for example, a nephrologist.

In order to figure this out right away and not spend extra money, we can tell you general but important information about edema:

1. You should visit a cardiologist if swelling occurs in the legs; it is symmetrical and painless, intensifies in the evening, and leaves a pit of doughy consistency after pressing. Additional symptoms include shortness of breath; the patient often has long-term chronic heart damage, for example, valvular defects, previous myocardial infarction or arrhythmia;
2. if swelling also occurs in the legs, but together with a feeling of heaviness in the calves, aching pain, night cramps, and appears after prolonged standing or long walking, and decreases overnight, then this is due to varicose veins of the lower extremities . This is especially true if, after a long period of such edema, spider veins, peeling of the skin, or the phenomenon of varicose dermatitis occur. We need a phlebologist or vascular surgeon;
3. if in this case the swelling of the leg is asymmetrical, on the one hand, the leg is hotter than the other, then, most likely, we are talking about thrombosis of the venous vessels, and here you need to contact a vascular surgeon;
4. if the patient has a long-term chronic pathology of the kidneys, swelling appears on the face, on the eyelids, does not change its location depending on changes in the state of the body in space, is not accompanied by shortness of breath, and in matcha tests a high protein is determined, more than 3 g per day, then speech It's about nephrotic syndrome. If the patient has high blood pressure and a small amount of urine, then it is necessary to urgently visit a nephrologist or kidney disease specialists;
5. if a person had jaundice, active hepatitis, cirrhosis was diagnosed, the amount of protein in the blood plasma was reduced, the level of bilirubin and transaminases was high, and his stomach swells like a drum, his navel protrudes, then everything is clear. We are talking about the development of ascites, or the accumulation of fluid in the abdominal cavity and portal hypertension, and here it is necessary to visit either a hepatologist for liver diseases, or an infectious disease specialist in the case of chronic viral hepatitis, or a surgeon.

Finally, if lymphatic edema associated with lymphostasis occurs, then at first the edema may be asymmetrical, on the one hand. But even if they become double-sided, they may also not be the same. At first these are soft swellings, like dough, they can intensify in hot weather, the skin over them easily moves. If they exist for a long time, then the skin over them thickens and becomes denser, the hole no longer remains, and in the later stages complete tissue fibrosis develops. The skin becomes lumpy and separated by deep folds. This happens when lymph nodes and lymphatic vessels are compressed, and in our country this most often occurs in advanced forms of cancer pathology. An urgent consultation is needed, first of all, with an oncologist.

Treatment of edema should always be comprehensive, and treatment should begin with attempts to eliminate the cause. So, if the cause is chronic heart failure, then it is necessary to enhance the work of the heart, for example, by using cardiac glycosides. In the presence of glomerulonephritis, it is necessary to use hormones and cytostatics; in the presence of hypothyroidism and myxedema, thyroid hormones must be prescribed, and so on.

However, in addition to etiotropic treatment aimed at the direct cause of edema, it is necessary to limit the intake of fluid, and for generalized edema it is necessary to limit salt intake, and one of the most important methods of pathogenetic treatment of edema syndrome is the prescription of modern diuretics, or diuretics. How are diuretics used, and what are diuretics? What caution should patients and physicians take when using them?

Furosemide

This diuretic is one of the most popular and frequently prescribed, and is a strong diuretic. Furosemide removes excess water and sodium salts from the body well and quickly, and relieves swelling. The drug is indicated for hypertension, poor functioning of the heart, kidneys and liver. Diuretic tablets begin to act 20-30 minutes after administration. Furosemide is usually used in emergency cases. You cannot take the drug without medical supervision, because self-medication can lead to dehydration. Furosemide is inexpensive, acts quickly, but has many side effects, including the removal of potassium and magnesium.

Furosemide

Sopharma, Bulgaria; PJSC "Biosintez", Russia; Binnopharm, Russia; JSC Avexima, Russia; Update, Russia; JSC Pharmstandard-TomskKhimPharm, Russia; "Moskhimfarmpreparaty" named after. N. A. Semashko, Russia; Ozon LLC, Russia; OJSC Borisov Plant of Medical Preparations (Borimed), Belarus; JSC Dalkhimfarm, Russia

Edema syndrome of various origins (with chronic heart failure, cirrhosis of the liver (portal hypertension syndrome); edematous syndrome of renal origin (with nephrotic syndrome, treatment of the underlying disease is in the foreground), acute heart failure, especially with pulmonary edema (used in combination with other therapeutic agents) measures); cerebral edema; severe forms of arterial hypertension; hypertensive crisis; forced diuresis in case of poisoning with chemical compounds excreted unchanged by the kidneys.
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Modern diuretics

Let us remind you once again that this material is intended, for the most part, not for patients suffering from edema syndrome, who are observed by a cardiologist for heart failure, and routinely take diuretics. Still, they are under the supervision of doctors and have a significantly lower risk of uncontrolled use of diuretics. This material is intended for those people who for some reason decided to use diuretics at their own risk.

It is no secret, for example, that the use of 1-2 tablets of furosemide in combination with intensive drinking of mineral water, vitamin C, and taking a hot shower can quickly eliminate a hangover and get a person in shape. Yes, forced diuresis is one of the effective means of removing the human body from a state of alcohol intoxication, and even from binge drinking.

But at the same time, it is necessary to remember the disadvantages that even the best modern diuretics have. Thus, treatment with these drugs alone, without correction of the ionic composition of the plasma, can lead to a large loss of fluid and mineral salts from the vascular bed, and this output will be greater than from the intercellular space. This can lead to a decrease in the amount of liquid part of the blood, or plasma, a decrease in the pumping function of the myocardium and a sharp drop in blood pressure, which can manifest as collapse. If the patient also has symptoms of heart failure, this will cause a reduced return of venous blood to the heart, and will further aggravate the low cardiac output.

Always, when using this or that diuretic, you need to find out about its capabilities, how powerful it is. Thus, thiazide diuretics, which act on the renal tubules and reduce carbonic anhydrase activity, are very common, and the most powerful are loop diuretics. Potassium-sparing diuretics can be considered quite mild and relatively harmless, since they have a rather weak effect.

Diuretics from the osmotic group, for example, Mannitol, will not be listed below. The scope of their application is completely different, for example, Mannitol is widely used in neuroreanimation and neurosurgery for the prevention and treatment of cerebral edema after surgery and in cases of severe traumatic brain injury. This section will not talk about those drugs for edema that reduce the symptoms of chronic venous insufficiency and are used in the treatment of varicose veins. These include various plant bioflavonoids, horse chestnut, rutin preparations, diosmin and others. They will be discussed in the relevant materials devoted to the treatment of varicose veins; their area of ​​application is completely different, and they are not diuretics.

We will look at diuretics that have a common mechanism of action and affect the kidneys. There are not many of these drugs, and there are not many commercial copies or generics of them. But in any case, the international nonproprietary name (INN) will be given first, then, if available, the original drug, which was first introduced to the market and has the largest number of studies on effectiveness and safety, will be named first. The various generics, or commercial copies, will then be named, followed by the price. Prices are valid for the beginning of spring 2022 for pharmacies of all forms of ownership on the territory of the Russian Federation.

The following list of medicines does not aim to create advertising or anti-advertising for any manufacturer or drug; all these medicines are included in the State Pharmacopoeia and are used in accordance with national and clinical recommendations for the management of patients with edematous syndrome. Some of the medications that cannot be found in pharmacies will not be listed here, as well as older, obsolete, rather toxic mercury diuretics.

Indapamide

This is a moderate-acting drug that is usually prescribed for edema associated with heart failure. "Indapamide" is quickly absorbed into the gastrointestinal tract. Diuretic tablets reduce the load on the heart and peripheral vessels and stabilize blood pressure. The effect occurs an hour after taking the drug and lasts 12-18 hours. You can buy Indapamide with a prescription, it is inexpensive, but it is a generic (not the original drug). Be sure to check the possible side effects.

Indapamide

OZON, Russia

Arterial hypertension;
sodium and water retention in chronic heart failure. from 8

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Veroshpiron

This is a potassium-sparing diuretic, which is prescribed for edema due to chronic heart failure and hormonal problems. And although Veroshpiron has a weak diuretic effect, the drug does not remove potassium and does not upset the acid-base balance in the body. The maximum effect of the diuretic occurs after 2-3 days and lasts a long time. You can buy Veroshpiron with a prescription; it is important to take into account the impressive list of contraindications.

Veroshpiron

Gedeon Richter, Hungary

The drug Veroshpiron is a potassium-sparing diuretic.
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Diuretic herbs

Herbs with a diuretic effect are prescribed by a doctor for extensive swelling of the face, arms and legs if there is kidney failure or severe inflammation of the urinary system. If conservative treatment methods have not brought visible results, then properly selected herbs can bring relief and solve the patient’s problem.

Many medicinal plants have a diuretic effect. The most popular, affordable and effective: chamomile, bearberry, rose hips, nettle, milk thistle. Diuretic herbal mixtures for edema can not only reduce the amount of fluid in the body, but also improve heart function. Hawthorn copes well with this serious task. Despite the fact that it has a weak diuretic effect, improving the functioning of the heart muscle allows you to eliminate edema and other unpleasant symptoms. Hawthorn goes well with bearberry, which enhances the diuretic effect.

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Torasemide

This diuretic drug is one of the most effective today. "Torasemide" is prescribed for acute and chronic heart failure, as well as renal failure. The product can also be taken to prevent edema. The drug effectively reduces high blood pressure by quickly removing excess fluid and sodium salts. The effect occurs an hour after administration and lasts 12-18 hours. Patients note that the diuretic effect does not occur immediately, so in the first hour after taking the drug you do not have to limit your activity. "Torasemide" is inexpensive and works well to relieve swelling of the face. You can buy diuretic tablets with a prescription; there are some side effects.

Torasemide

Berezovsky Pharmaceutical Plant, Russia

Edema syndrome of various origins, incl.
for chronic heart failure, diseases of the liver, kidneys and lungs; - arterial hypertension. from 81

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Triampur compositum

This diuretic does not have a very pronounced effect and does not remove potassium from the body, only water, salts and toxins. That is why Triampur compositum is considered the safest diuretic drug, which is prescribed for edema due to chronic heart failure and liver problems. Triampur begins to act 15 minutes after administration, and the effect lasts about 12 hours. Doctors say that this diuretic is safe for relieving facial swelling, is quickly absorbed into the gastrointestinal tract, and has a gentle effect.

Triampur compositum

AVD.pharma, Croatia

-arterial hypertension;
—edematous syndrome of various origins (with chronic heart failure, nephrotic syndrome, liver cirrhosis). from 256

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Diuver

Modern diuretic tablets from the group of loop diuretics. The active ingredient of the drug, turasemide, copes well with edema of various natures. “Diuver” has the mildest, prolonged action; the effect after administration occurs within 3-4 hours. Although it is not a potassium-sparing diuretic, it removes much less potassium than other diuretics. Diuver is prescribed for diseases of the kidneys, liver, lungs and heart failure. You can buy Diuver with a prescription (by the way, it is not cheap), be sure to familiarize yourself with the contraindications and side effects.

Diuver

JSC "Biolek", Ukraine

- edematous syndrome of various origins, incl.
for chronic heart failure, diseases of the liver, kidneys and lungs; - arterial hypertension. from 236

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Natural Diuretics

Photos from open sources

Dog-rose fruit

In addition to medicinal diuretics, herbal drugs have a mild diuretic effect. Firstly, it is rosehip. In addition to being a diuretic, it is famous for its general strengthening effect, helping the body resist various infections (also for urinary tract diseases). Rosehip improves the functioning of the digestive and cardiovascular systems. The value of rosehip is that it contains a lot of useful vitamins. Rose hips relieve swelling, reduce cholesterol levels, normalize blood clotting, and help cells recover faster.

Rosehip fruits

OJSC Krasnogorskleksredstva, Russia

For the prevention of hypovitaminosis C and R. In the complex therapy of acute and chronic infectious diseases, asthenic conditions, during the period of recovery after serious illnesses, surgical operations
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Diuretic collection

Herbal infusions are very popular for the treatment of many diseases, including as a diuretic for edema. Diuretic collection in complex treatment helps cure urinary tract infections. Medicinal herbs in the diuretic collection act very gently, relieve spasms and inflammation. A diuretic preparation is often prescribed for cystitis; it is suitable for preventing relapses of this disease and is available in almost every pharmacy. Disadvantages include an unpleasant taste and green coloration of urine.

Diuretic collection

ST-Medipharm, Russia

Combined product of plant origin.
It has diuretic, anti-inflammatory, antiseptic, antispasmodic effects. from 76

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Folk remedies and herbs

Many people prefer folk remedies to potent medications, and in the case of diuretics, in most cases this choice is justified .

Know! Folk remedies do not have so many side effects and contraindications; another question is whether they will be as effective as traditional medicines.

For swelling, we can recommend the following remedies for use at home :

1. A spoonful of dried herb called shepherd's purse is brewed in a glass of boiling water and infused for ten minutes . The cooled product is drunk at one time. A day you need to prepare and drink three servings of this drug, which is consumed before meals.
2. Dill, mint, chicory, yarrow and nettle are mixed in equal proportions (it does not matter whether such herbs are used fresh or dried). A teaspoon of this collection is poured with 200 grams of boiling water and infused for up to twenty minutes . You can drink this portion in one or two doses if desired. If you are not allergic to honey, you can add a teaspoon of this product to the infusion.
3. A herbal mixture of plantain, bearberry, St. John's wort, rose hips and nettle in equal proportions is poured into 0.5 liters of boiling water . In this case, a tablespoon of the mixture is enough for this amount of water. The finished product is consumed three times a day.
4. A teaspoon of crushed bearberry with the addition of a few grams of black or green tea is poured into a glass of water and infused for up to ten minutes . You need to drink this remedy half an hour before meals.
5. yourself , which contains only lingonberry leaves in the amount of a teaspoon per glass of boiling water. This remedy must be used at least four times a day.

Important! Do not forget that all these drugs have a diuretic effect, so using them in large quantities and for a long period of time (longer than a week) is not recommended.

Juniper fruits

Juniper helps with urinary tract infections by reducing inflammation and destroying germs. And thanks to the diuretic effect, pathogenic microflora is quickly eliminated from the body. Juniper fruits are also used as an appetite stimulant and to improve the functioning of the gastrointestinal tract. In addition, this herbal preparation stabilizes blood pressure and has a mild laxative effect. Contraindications include pregnancy, breastfeeding and childhood.

Juniper fruits

OJSC Krasnogorskleksredstva, Russia

In the complex treatment of edematous syndrome (with heart failure, insufficiency of kidney and/or liver function), cystitis
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