Diuretic tablets with edema of the legs in the elderly
Currently accumulated great factual material on the characteristics of the effects of many medicinal productsfunds for the organism of the elderly and old people in comparison with people younger. In older people, the side effects of medications are much more frequent and more severe when administered at generally accepted dosages. In this respect, the most frequent complications in elderly and old people in the treatment of diuretics by edematous conditions are particularly indicative.
The most frequent complications in the application ofdiuretics in geriatric patients are shifts in water-salt metabolism and acid-base balance. This is due to the aging of certain changes in the state of the body, the decrease in the reliability of the mechanisms of regulation of homeostasis. So, with age in the body decreases the content of potassium. increases shifts in acid-base equilibriumtowards acidosis. In this case, pathological changes in the functional state of water-salt metabolism and acid-base state in elderly and old people can develop from insignificant harmful factors, whereas normalization of their functional state is much slower than in young people.
The study of the effect of various diuretics onpeople of young, elderly and senile age testifies that in the older age groups shifts in electrolyte metabolism and acid-base balance under the influence of identical doses of diuretics are always much more pronounced than in young. And increasing the dose of the drug, as a rule,does not cause a further increase in diuresis in elderly patients, but always further deepens the shifts in the electrolyte and acid-base balance. The recovery period in these patients is more prolonged.
Regarding the dosage of diuretics whentreatment of edematous conditions in people of elderly and senile age, here it is necessary to be guided not by generally accepted doses, but by the effect achieved and to cancel these drugs as soon as refractory (stability) comes to them. Older people respond better to small doses of diuretics and drugs with delayed diuretic action(veroshpiron, aldactone, hygroton). This is due to the fact that with a slowly increasing small diuresis and sodium nerve cuts, electrolyte and hemodynamic shifts do not occur so dramatically and as a result, reflex excitation of the counteracting mechanisms that cause refractoriness to diuretic drugs is less pronounced.
In connection with the expressed losses of electrolytes,rapidly advancing refractoriness and a long recovery period after taking saluretics in elderly and old people, the course of taking diuretics should be reduced in comparison with the generally accepted one, and the time between courses should be increased.
Experience shows that if an elderly person does not have a diuretic reaction to the first dose of a diuretic, his appointment even in high doses is useless. In cases of refractory to saluretic beforethe appointment of the main drug should create a "potassium background", appointing 2-3 days of potassium preparations in large doses (2-3 grams per day) or spironolactone. To some extent, but almost always refractivity for a certain period is reduced by the joint appointment of various diuretics, different in the mechanism of action and "place of application" in the nephron, and their effect on electrolyte metabolism and acid-base balance should be multidirectional. However, the best effect with persistent swelling, as a rule, is observed in the combined appointment of saluretics with aldosterone blockers. In addition, with such swelling sensitivity to diuretics can often be restored by the appointment of small doses of glucocorticoids (10-15 mg per day).
In all cases of treatment of elderly and old people with saluretic diuretics correction of potassium exchange is necessary. Deficiency of potassium, violation of its relationships with other electrolytes lead to a drop in myocardial tone, a violation of the heart rhythm, contribute to the manifestation of toxic properties of digitalis.
Common means of correction of potassiumexchange and acid-base state are various pharmacological preparations of potassium (potassium chloride, panangin, asparcams, potassium orotate). In this case, the replacement effect has only large doses. However, due to the decrease in intracellular metabolism with age, the absorbed potassium can be "transits" through the kidneys. Inclusion of it in metabolic processes is promoted by glucose, insulin, vitamins.
Given the reduced absorption of potassium in the intestine with age. The best method of correction of potassium metabolism inelderly people in the treatment of saluretics is the preservation of endogenous potassium by the parallel assignment of potassium-sparing diuretics. An important and sometimes decisive role in the correction of electrolyte metabolism is played by the corresponding potassium diet.
To enhance the therapeutic effect of diureticsmeans and reduction of their side effects in geriatric practice should be prescribed together with vitamins, since some of them (B6, C) directly have a potentiating effect on diuretics.
If the elderly and old people have cardiacdeficiency arose against a background of hypertension, then diuretics should be prescribed to them, reducing the doses of other antihypertensive agents, since diuretics themselves have the ability to reduce blood pressure.
Massive therapy with diuretics leads to large losses of fluid from the body. including from the bloodstream, thatincreases the viscosity of the blood, enhances its hypercoagulability. In addition, cardiac glycosides, often prescribed in parallel with diuretics, significantly exacerbate hypercoagulant shifts caused by diuretics. This should be taken into account in the appointment of diuretics to the elderly, who already and under normal conditions there is a tendency to hypercoagulable.
Be careful and take special account ofthe mechanism of action of the drug when prescribing saluretics to patients with fresh thrombosis and renal insufficiency. In addition, one must take into account the possibility of idiosyncrasy to the diuretic used.
In elderly and old people with poorly expressededema, especially of cardiac origin, shows xanthine diuretics (diuretin, theophylline, and euphyllin). The absence of changes on the part of electrolyte metabolism and acid-base balance under the influence of xanthine diuretics, their ability to expand coronary, cerebral, renal and pulmonary vessels, to eliminate bronchospasm and to reduce blood pressure cause a fairly wide use of these drugs in geriatrics. Of particular practical importance is the combined use of xanthine diuretics with saluretic diuretics. With the joint appointment of these diuretics, the diuretic effect is summed up without increasing the loss of potassium.
A wide distribution in geriatric practice was hypothiazide. It is effective for any pathology with swellingsyndrome, especially in the chronic course of the disease. Hypothiazide has a vasodilator and hypotensive effect, increases renal blood flow and glomerular filtration. A positive aspect in the mechanism of hypothiazide in elderly and old patients is that the increase in diuresis under the influence of this drug is mainly due to the reduction of extracellular fluid, since with age and in healthy people there is already a deficit of intracellular water. At the same time, hypothiazide causes a decrease in the potassium level and a shift in the reaction of the state of the internal environment towards alkalosis. These negative properties are more pronounced in elderly and old people. Therefore, use of hypothiazide in elderly and old people, preferably in small doses (25 mg twice a day), the duration of the course should not exceed 3-4 days, re-administration of the drug probably not earlier than 3-5 days.
The most common a representative of the sulfanilamide diuretic group - carbonic anhydrase blockers is diacarb. It causes in elderly and old people quitesatisfactory diuretic reaction, well tolerated. He is most shown in the treatment of heart failure. The drug is recommended to use 250 mg once a day for 2-3 consecutive days with a break of 2-3 days with mandatory correction of potassium metabolism, but not potassium chloride. Contraindicated in cirrhosis, kidney disease, uremia.
The group of sulfanilamide derivatives includes andOxodoline (hygroton), which also has a potassium -uretic effect. Very valuable for geriatric properties of the hygroton are a significant duration of its action and a moderate, permanent diuretic effect. With sufficient correction of the potassium exchange hygroton can be used for a long time. The best diuretic effect of the drug is observed with cardiovascular failure in the initial stages of decompensation.
Modern highly active diuretics - Lasix. ethacrylic acid in geriatric practiceshould be used with caution, under strict medical supervision, because due to a very fast and strong diuretic action, they can in a relatively short period lead the body of an elderly person to dehydration. In this case, large losses of sodium and water under the influence of these drugs lead to an increase in the activity of the renin-aldosterone system and the appearance of refractoriness not only to the drug used, but also to other saluretic drugs. In acute conditions, highly active diuretics, of course, should be the subject of choice.
The most common lazix for the elderly and old peopleappoint 20 to 40 mg 1 to 2 times a day in short courses (2-3 days) with an interval of 2 to 4 days. Supportive therapy - 40 mg 1 - 2 times a week. A similar scheme is also used when using ethacrynic acid 25-50 mg 1-2 times a day for 2-3 days. Correction of potassium exchange is necessary.
In recent years,new diuretic drug klopamid (brinaldix). According to the diuretic effect, it is slightly inferior to lazix and ethacrynic acid, but unlike the latter, it almost does not cause loss of potassium by the body, which is especially important in geriatric practice. In addition, as our studies have shown, brinaldix has a good antihypertensive effect, favorably affects hemodynamics in patients with hypertensive disease of the elderly and senile age. With edematous conditions, the drug is better to prescribe 10 mg (1/2 tablet) 2 times a day for 3-4 days in the form of repeated courses with a break between them 2-3 days.
Potassium-preserving effect is also possessed by triamterene. It has a pronounced diuretic effect not only in heart failure, but also with edematic renal syndrome (cirrhosis of the liver, etc.). The ability of triamterene to delay the release of potassium from the body makes it possible to successfully use it for cardiac glycoside intoxication. Finally, unlike many other diuretics, triamterene enhances the release of uric acid and therefore it can be used even in patients with concomitant gouty conditions. The drug is prescribed for 1 capsule (0.05 g) 2 times a day for three days with a break between them 3-4 days.
Well established in the clinicThe combination of triamterene with hypothiazide served as the basis for the creation of a new drug called triampur. This drug is a combination of triamterene with hypothiazide in a quantitative ratio of 2: 1 (0.025 g. 0.0125 g). Elderly drug is better to prescribe 1 tablet 2 times a day for 3-4 days with a break between them 2-3 days. Supportive doses - twice a week for 1 tablet 2 times a day.
In the treatment of edematous conditions in geriatrics, allMore widely used are spironolactones - aldosterone blockers. Of particular importance for geriatrics is the ability of aldosterone inhibitors to retain in the body not only potassium, but also magnesium, and therefore they are ideal tools for correcting electrolyte imbalance in the treatment of ordinary diuretics, and when combined, they significantly enhance the diuretic effect of the latter. It is important to note that spironolactones do not reduce renal blood flow and glomerular filtration, improve coronary circulation, reduce the increased excitability of the myocardium during cardiac decompensation.
The use of spironolactones in patientsatherosclerotic myocardiosclerosis with circulatory failure improves potassium exchange in the body, positively affects the contractile ability of the myocardium, helps restore the rhythm of cardiac activity.
Veroshpiron elderly people appoint 25 mg of 4once a day, better together with small doses of saluretics. Veroshpiron is also used to create a "potassium background" in cases of refractory edema. 2-3 days before the appointment of the main diuretic, veroshpiron is prescribed for 100-200 mg per day.
Diuretic properties, similar to those of a group of spironolactones, has progesterone. Combination of it with other diuretics enhancesdiuretic reaction of the latter and reduces the release of potassium. Among the valuable qualities of progesterone should be attributed to the positive effect of the drug in cirrhosis and developing ascites, as the treatment of such patients is often very difficult. To do this, usually use a half dose of the basic diuretic in combination with 1 ml of 0.5% progesterone oil solution intramuscularly once a day for 3-4 days followed by a break of the same duration.
For the treatment of refractory edema in geriatricIt is better to use various combinations of diuretics: hypothiazide with diacarb, furosemide with triamterene, ethacrylic acid with triamterene, furosemide with diacarb, hypothiazide with triamterene, furosemide with veroshpiron, etacrynic acid with veroshpyron, hypothiazide with verospheron, etc. (see table).
In the cases persistent edema sensitivity to diuretics is often managed to restore the appointment of glucocorticosteroids. In the absence of contraindications, the use of corticosteroids in elderly people should start with small doses (10-15 mg of prednisolone per day), fractionally 2-3 days before the main saluretic is connected.
Diuretic effect of diuretics insignificantly depends on the regime and especially the patient's diet; properly organized regimen and diet, selected in accordance with the mechanism of action of the diuretic used, potentiates its diuretic effect; otherwise, it soon becomes addictive to the drug and the occurrence of side effects.
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