CONTINUING EDUCATION DRUG/STRENGTH(S)/ MANUFACTURER(S)
INITIAL INITIAL DOSE MAXIMUM DURATION DOSE & & TITRATION DAILY DOSE OF ACTION TITRATION IN ELDERLY IN ADULTS/ IN ADULTS ELDERLY 200mg 6 to 12 Hydrochlorothiazide 25 mg once Initial: 12.5 mg once daily; titrate hours 12.5 mg capsule/tablet or twice daily in increments of 25 mg tablet 12.5 mg 50 mg tablet Various manufacturers (Microzide®)
POSSIBLE ADVERSE REACTIONS Electrolyte disturbances/ Photosensitivity/ contraindication in patients with a prior allergic reaction to sulfonamides
Indapamide
2.5 mg once daily
Use with caution
5 mg
36 hours
Electrolyte disturbances/ Photosensitivity/ contraindication in patients with a prior allergic reaction to sulfonamides
Metolazone
2.5 mg once daily
Use with caution
20mg
12 to 24 hours
Electrolyte disturbances/ Photosensitivity/ contraindication in patients with a prior allergic reaction to sulfonamides
1.25mg tablets 2.5mg tablets Various manufacturers
2.5mg tablets 5mg tablets 10mg tablets Various manufacturers (Zaroxolyn®)
COMMENTS
Renal impairment -no dosage adjustments provided in the manufacturer's labeling -Usually ineffective with CrCl <30 mL/minute unless in combination with a loop diuretic.CrCl <10 mL/minute: Use not recommended. Hepatic impairment-no dosage adjustments provided in the manufacturer's labeling Renal impairment -There are no dosage adjustments provided in the manufacturer's labeling GFR <10 mL/minute: 1.25 to 2.5 mg once daily Hepatic impairmentno dosage adjustments provided in manufacturer’s labeling Renal impairment-no dosage adjustments provided in the manufacturer’s labeling -use with caution in those with renal impairment as renally excreted Hepatic impairment-no dosage adjustments provided in the manufacturer’s labeling
POTASSIUM-SPARING DIURETICS* pyrazine-carbonyl-guanidine Mechanism of Action: inhibition of sodium reabsorption at the distal convoluted tubule, cortical collecting tubule and collecting duct; this decreases the net negative potential of the tubular lumen and reduces both potassium and hydrogen secretion and their subsequent excretion. 5 mg once Use lower 20mg 24 hours Electrolyte Renal impairment-caution Amiloride 5mg tablet Various manufacturers
daily
dose-decreased clearance : use with caution
disturbancesHyperkalemia
in those with DM or SCr >1.5 mg/dL, or BUN >30 mg/dL Hepatic impairment -no dosage adjustments provided in the manufacturer’s labeling **Administered with food
ALDOSTERONE ANTAGONIST Mechanism of Action: Competes with aldosterone for receptor sites in the distal renal tubules, increasing sodium chloride and water excretion while conserving potassium and hydrogen ions; may block the effect of aldosterone on arteriolar smooth muscle as well 12.5 to 25 Avoid use of 50mg ** 1 to 3 hours Electrolyte Renal impairmentSpironolactone
25mg tablet 50 mg tablet 100mg tablet Various manufacturers (Aldactone®)
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Insight
mg once daily
tablets >25 mg/ day in elderly patients with heart failure or with reduced renal function (eg, CrCl <30 mL/minute or eGFR ≤30 mL/ minute/1.73 m2.
disturbancesHyperkalemia Gynecomastia
contraindicated in those with low urine output/Use with caution in those with renal impairment - eGFR 30 to 50 mL/minute/1.73 m2: Initial: 10 mg once daily. eGFR <30 mL/minute/1.73 m2: There are no specific dosage adjustments provided in the manufacturer's labeling./ Hepatic impairment-no dosage adjustments provided in the manufacturer's labeling