CLINICAL REVIEW
Diuretics: how they work,
cautions and contraindications
Health professionals have an important role to play in promoting adherence and
ensuring that quality of life is not compromised for patients taking diuretics, which
can reduce fluid reabsorption in the kidneys, as Gerri Kaufman explains
D
iuretics are substances that increase the
secretion of water from the body through
their action on the kidney (Kaufman, 2013).
Diuretics are prescribed to manage conditions
that are associated with the retention of excessive
amounts of fluid such as hypertension and heart failure
(Harvey and Jordan, 2010). Diuretics can be divided
into three classes: loop diuretics, thiazide diuretics and
potassium-sparing diuretics (Bennett, 2008) (Box1).
Diuretics are widely prescribed and when used
appropriately, are considered efficacious, cost effective
and generally well tolerated (Bennett, 2008). However,
diuretics are overprescribed in older people who are par-
ticularly susceptible to their side effects, which include
electrolyte disturbances (especially hypokalaemialow
serum potassium that can have significant consequenc-
es such as abnormal heart rhythms and cardiac arrest),
dehydration and hypotension (low blood pressure, which
can cause falls in older people) (Kaufman, 2013). Elec-
trolytes include substances such as sodium, potassium,
hydrogen and magnesium. They need to be maintained
at appropriate levels within the body. Diuretics can alter
their balance within the body.
This article will explore the different classes of
diuretics and discuss the ways in which they affect the
body. The cautions and contraindications of diuretics
will be noted and the side effects considered. Finally,
practical issues in relation to the use of diuretics will be
addressed.
Indications for use and
mechanism of action
Loop, thiazide and potassium-sparing diuretics increase
the secretion of water from the body by inhibiting the
normal reabsorption of electrolytes, especially sodium
from the kidney back into the circulation. This leads to
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the retention of electrolytes and water, produces a larger
volume of urine for excretion and causes a reduction in
the circulating blood volume (Simonsen et al, 2006).
The different classes of diuretics have a particular site
of action within the kidney (Harvey and Jordan, 2010).
NRC | February 2014, vol 16, no 2
Loop diuretics
Loop diuretics, which include furosemide and bumetanide
are the most powerful diuretics (Khatib, 2011). They are
preferred over others because they produce a strong diure-
sis and maintain their diuretic effect in renal impairment
(Khatib, 20011).
Loop diuretic are so called because they act in a part of the
nephron known as the ascending limb of the loop of Henle
(Greenstein and Gould, 2009). Loop diuretics are responsible
for blocking the reabsorption of 2030% of water and
electrolytes from the urine back into the circulation (Harvey
and Jordan, 2010). These drugs are therefore important in
the management of the fluid retention associated with heart
failure that results in ankle oedema, pulmonary oedema
and breathlessness (Khatib, 2011). The loop diuretics work
by removing excess fluid, which in turn, relieves oedema,
congestion and breathlessness. Furosemide and bumetanide
act within 1 hour of oral administration and diuresis is
complete within 6 hours (Joint Formulary Committee,
2013). This means that, if required, they can be given
twice daily without causing interference with sleep (Joint
Formulary Committee, 2013).
Thiazides and thiazide-like diuretics.
The thiazide diuretics, which include bendroflumethiazide
and indapamide, act in a part of the kidney known as the
distal convoluted tubule and prevent the reabsorption of of
up to 10% of water and electrolytes water and electrolytes
(Harvey and Jordan, 2010). Therefore, a smaller diuresis
is usually associated with the thiazides compared to the
loop diuretics (Harvey and Jordan, 2010). The thiazide
diuretics act within 12hours of administration, and most
have a duration of action of 1224hours (Joint Formulary
Gerri Kaufman Senior Lecturer, Department of Health
Sciences, University of York
gerri.kaufman@york.ac.uk
83
CLINICAL REVIEW
Distal convoluted tubule
Thiazides and thiazide-like
diuretics
Loop diuretics
Potassium-sparing diuretics
Loop of Henl Collecting duct
Figure 1. Different diuretic actions
Committee, 2013). They are normally administered early
in the day so that the diuresis does not interfere with sleep
(Joint Formulary Committee, 2013). Thiazide diuretics can
be used in patients with mild heart failure (Khatib, 2011)
and good renal function (Joint Formulary Committee,
2013). They are, however, ineffective in patients with renal
impairment (Joint Formulary Committee, 2013). In patients
with heart failure, where diuresis with a single diuretic is
insufficient, a combination of a loop diuretic and a thiazide
may be tried (Joint Formulary Committee, 2013). This may
be particularly useful in resistant chronic heart failure
as loop diuretics and the thiazides can have a synergistic
effect (Bennett, 2008). However, care must be taken when
combining both types of diuretics because they may induce
a significant diuresis, which puts the patient at risk of
hypotension and dehydration (Bennett, 2008).
Thiazide diuretics also have a place in the management
of hypertension (high blood pressure) (National Institute for
Health and Care Excellence (NICE), 2011). Hypertension
is one of the most preventable causes of heart disease and
stroke in the UK (Linden, 2011). Diuretics reduce systolic
and diastolic blood pressure by increasing the loss of sodium
and water (Bennett, 2008). This reduces the volume of
fluid in the circulation (Harvey and Jordan, 2010) and
lowers blood pressure. The use of a thiazide diuretic is
recommended in the NICE (2011) stepped approach to the
clinical management of primary hypertension in adults.
Bennett (2008) suggests that, for most patients with normal
renal function, thiazides offer better control over blood
pressure compared to loop diuretics. However, according
to NICE (2011) chlortalidone and indapamide are the
preferred diuretics in the management of hypertension.
84
Box 1. Examples of diuretic drugs
Loop diuretics
Furosemide
Bumetanide
Torasemide
Thiazide diuretics
Bendroflumethiazide
Metolozone
Chlortalidone
Indapamide
Potassium sparing diuretics
Spironolactone (Aldosterone antagonist)
Eplerenone (Aldosterone antagonist)
Amiloride
Triamterene
From: Bennett, 2008; Kaufman, 2013.
Potassium-sparing diuretics
Potassium-sparing diuretics act on the collecting tubules
of the kidney and block the loss of potassium. They
include two main classes of weak diuretics that are rarely
given alone. However, they can be administered alongside
loop and thiazide diuretics to improve the therapeutic
response (Bennett, 2008). The first group of potassium-
sparing diuretics comprise the aldosterone antagonists
spironolactone and eplerenone. Rather than directly
affecting sodium transport, these drugs inhibit the action of
aldosterone, which is a hormone that increases the secretion
of potassium and reabsorption of sodium and water
(Hennefer, 2010). By inhibiting the action of aldosterone,
these drugs increase the excretion of sodium and water
but at the same time spare the excretion of too much
potassium. This is important to prevent low potassium levels
(hypokalaemia), which can be dangerous (Hennefer, 2010).
These drugs have a fairly slow action as it can take
23 days for an effect to be observed. However, their ac-
tion can then last for a further 23days (Bennett, 2008).
The second group of potassium-sparing diuretics include
amiloride and triamterene. Of the two, amiloride is slower
acting, and it can take around 6hours for the effects to oc-
cur. However, once the effects occur, they can persist for
up to 24 hours. Triamterene has an effect 2 hours after
administration and the effects can persist for 1216 hours
(Bennett, 2008).
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Cautions, contraindications
and side effects
Diuretics should be administered with caution and doses
adjusted according to patient monitoring (Harvey and
Jordan, 2010). Older people are particularly susceptible to
NRC | February 2014, vol 16, no 2
 CLINICAL REVIEW

Box 2. Cautions and contraindications of diuretics

Class of diuretics Cautions and contraindications
Loop diuretics Hypovalaemia and hypotension should be corrected before starting treatment with
loop diuretics
Electrolytes should be monitored during treatment
Loop diuretics can exacerbate diabetes and gout
Urinary retention can occur if there is an enlarged prostate
Loop diuretics should be avoided in severe hypokalaemia (hypokalaemia (low blood potassiu)
induced by loop diuretics can precipitate hepatic encephalopathy (confusion)and coma), severe
hyponatraemia (low blood sodium), anuria (lack of urine production), comatose and precomatose
states associated with liver cirrhosis (scarring), renal failure due to nephrotoxic (medicines harmful
to the kidney) or hepatotoxic drugs (medicines harmful to the liver) and severe liver disease
High doses or rapid intravenous administration can cause tinnitus and deafness
High dose bumetanide can cause musculoskeletal pain
In pregnancy: furosemide and bumetanide should not be used to treat hypertension
Thiazide diuretics Thiazide diuretics can exacerbate diabetes and gout and systemic lupus erythematous (a complex
condition that is caused by problems with the immune system resulting in fatigue, skin rash and
painful and swollen joints)
Thiazide diuretics should be used with caution in nephrotic syndrome and mild to moderate
hepatic impairment
Electrolytes should be monitored with the administration of high doses, long-term use and in
renal impairment
Thiazides should not be used to treat hypertension in pregnancy
Potassium-sparing Potassium supplements must not be given with potassium-sparing diuretics
diuretics Potassium-sparing diuretics can cause hypokalaemia if administered with an angiotensin-
converting-enzyme (ACE) inhibitor or an angiotensin 2 receptor antagonist
Potassium-sparing diuretics should be avoided in hyperkalaemia, anuria, Addisons disease (a
disorder of the adrenal glands) and severe renal impairment
When prescribed for individuals with renal impairment, the plasma-potassium concentration
should be monitored
Not recommended in pregnancy or breastfeeding
From: Joint Formulary Committee, 2013.

the side effects of diuretics and should be prescribed lower
doses initially. The dose can then be adjusted according
to renal function (Joint Formulary Committee, 2013).
Cautions and contraindications common to the majority of
diuretics are listed in Box 2.
However, the Joint Formulary Committee (2013) and the
summaries of product characteristics for individual diuretics
provide much more detailed information about cautions,
contraindications and side effects. The summaries of
product characteristics can be accessed at: www.medicines.
org.uk/emc
The following are examples of some of the most commonly
encountered side effects.
Hypotension
All diuretics can cause hypotension and postural
hypotension; therefore, blood pressure should be carefully
monitored. It may be necessary to reduce the diuretic dose
to manage symptomatic hypotension (Khatib, 2011).
However, sometimes this is difficult as failure worsens so the
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be given when administering diuretics to older people, as
hypotension can cause falls (Hennefer, 2010). Older people
are more susceptible to fractures if they fall due to a loss of
bone density that occurs with ageing (Kaufman, 2013).
Electrolyte imbalance
All diuretics can cause hyponatraemia (low serum sodium),
but it is more common with thiazide diuretics (Khatib,
2011). It is recommended that residents taking diuretics
serum sodium concentrations should be monitored (Har-
vey and Jordan, 2010); urea and electrolytes should be
monitored at least twice a year. A rapid fall in sodium can
adversely affect brain cells and cause lethargy, headache,
anorexia, nausea, vomiting and confusion that can progress
to seizures (Harvey and Jordan, 2010). In vulnerable older
people with mildly impaired renal function, the loss of cir-
culating fluid caused by administration of the diuretic can
trigger the release of antidiuretic hormone, which in turn
causes water retention and resistance to diuretic therapy
(Harvey and Jordan, 2010). Mild hyponatraemia may be as-

dose can be split, e.g. 40 mg furosemide twice daily rather
than 80 mg in the morning. Co-administration of other
drugs with diuretics and self-administered diuretics such as
tea, coffee and herbal remedies can also cause hypotension
(Harvey and Jordan, 2010). Special consideration should
sociated with impaired gait, increasing the risk of falls and
fractures in older people (Harvey and Jordan, 2010).
The administration of diuretics is associated with
hypokalaemia (low serum potassium), which can have
serious consequences, such as cardiac dysrhythmias or

NRC | February 2014, vol 16, no 2 85

CLINICAL REVIEW
arrest. Indications of a low serum potassium level include
palpitations, fatigue, depression, constipation and cramps
(Harvey and Jordan, 2010). Potassium-sparing diuretics can
be prescribed if the serum potassium falls below 4 mmol/L.
Potassium supplements are rarely necessary and residents
should be advised to eat potassium-rich foods, such as fresh
vegetables, meat and fish (Harvey and Jordan, 2010).
Renal impairment
All classes of diuretics are implicated in precipitating renal
impairment (Khatib, 2011). Consequently, renal function
should be monitored carefully in patients taking diuretics.
It is recommended that doses are reduced or diuretic ther-
apy is suspended temporarily if renal function deteriorates
(Khatib, 2011).
Diuretics can also cause calcium and lipid imbalance and
the loop and thiazide diuretics are associated with a rise in
urate levels which can precipitate gout. Loop diuretics can
affect hearing and balance but this is usually reversible.
Thiazide diuretics are associated with male impotence but
this can also be caused by other drugs prescribed for car-
diovascular problems. In patients taking other drugs as well
as diuretics for cardiovascular problems, it is important to
establish exactly when the problem began (Harvey and Jor-
dan, 2010).
Practical considerations
When initiating diuretic therapy, there are a number of
practical considerations. Where possible, oral administra-
tion should be linked to mealtimes to minimise gastrointes-
tinal upset (Harvey and Jordan, 2010). It is important to
consider the diuretic effect and lifestyle of the resident when
timing the dose of the diuretic (Bennett, 2008). It is essential
that the diuretic effect does not interfere with the residents
sleep; therefore, once daily administration after waking is
often more appropriate than administration at other times
(Bennet, 2008).
However, some residents may find that morning adminis-
tration exacerbates incontinence. This is because morning
administration results in drug-induced diuresis that coin-
cides with the natural 24hours rhythms in urine excretion
(maximum diuresis occurs at approximately 8 am) (Jordan
Key points
Diuretics are widely prescribed
They are used in the treatment of hypertension and heart failure
Loop diuretics are the most powerful diuretics
A smaller diuresis is usually associated with thiazide diuretics compared to
loop diuretics
Potassium sparing diuretics are the weakest of the diuretics and rarely used alone
Diuretics are associated with adverse effects and patients taking them
should be monitored carefully
86
and Harvey, 2010). Administration at lunch time or later
can resolve the problem. Where divided doses are required
it is often most acceptable to give the second dose 68 hours
after the first (Bennett, 2008). Excessive diuresis can cause
functional incontinence, and it is important that toilet facili-
ties are close at hand when diuretics are first prescribed. In
situations where diuresis is affecting quality of life, and dose
reduction is not an option, substitution with another diuret-
ic that has a longer duration of action may help to normalise
micturition patterns (Harvey and Jordan, 2010).
Diuretics are drugs that are frequently prescribed but
patients often stop taking them (Crouch and Chapelhow,
2008). Poor adherence to diuretics may be associated with
unpleasant adverse effects such as incontinence, impotence
or joint pains (Harvey and Jordan, 2010). It is essential that
the diuretic prescribed is acceptable to the resident. Many
are given little information about the effects of diuretics
and how best to manage them (Crouch and Chapelhow,
2008). It is important that health professionals explore the
effect of the diuretic on the residents lifestyle (Crouch and
Chapelhow, 2008; Harvey and Jordan, 2010). Adherence to
medication has important health benefits, which has been
illustrated in large trials that demonstrate that diuretics save
and prolong lives for people with hypertension (Jordan and
Harvey, 2010). On the other hand, non-adherence to diuret-
ics is implicated in the deterioration and hospitalisation of
individuals with heart failure (Harvey and Jordan, 2010).
Conclusion
Diuretics are drugs widely prescribed to reduce fluid
reabsorption in the kidneys and increase the loss of water
from the body. They are used in the management of
conditions such as heart failure and hypertension. However,
diuretics are associated with adverse effects and careful
patient monitoring is required to ensure these drugs have a
therapeutic effect. In addition, health professionals have an
important role to play in promoting adherence and ensuring
that quality of life is not compromised for patients taking
diuretics. NRC
This article has been subject to double-blind peer review.
Bennett S (2008) Diuretics: use, actions and prescribing rationale. Nurse Pre-
scribing 6(2): 727
Crouch S, Chapelhow C (2008) Medicines Management. A Nursing Perspective.
Pearson Education Limited, London
Greenstein B, Gould D (2009) Trounces Clinical Pharmacology for Nurses. 18th
edn.Churchill Livingstone, London
Harvey S, Jordan S (2010) Diuretic therapy: implications for nursing practice.
Nurs Stand 24(43): 409
Hennefer D (2010) Pharmacologya systems approach: renal system. British
Journal of Healthcare Assistants 4(1): 3841
Joint Formulary Committee (2013) British National Formulary. No 66. BMJ
Group and RPS Publishing, London
Kaufman G (2013) Prescribing and medicines management in older people.
Nurs Older People 25(7): 3341
2014 MA Healthcare Ltd
Khatib R (2011) Prescribing diuretics in the management of heart failure.
Nurse Prescribing 9(9): 43541
Linden B (2011) NICE guidance on primary hypertension. British Journal of
Cardiac Nursing 6(12): 5824
National Institute for Health and Care Excellence (2011) Hypertension, Clini-
cal management of primary hypertension in adults. NICE Clinical Guideline
127. NICE, London
Simonsen T, Aarbakke J, Kay I, Coleman I, Sinnot P, Lysaa R (2006) Illustrated
Pharmacology for Nurses. Hodder Arnold, London
NRC | February 2014, vol 16, no 2
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