Diuretics are pharmacological agents that promote the excretion of water and electrolytes (primarily sodium and chloride) from the body via the kidneys, increasing urine output. They are primarily used in the management of hypertension, edematous states (such as congestive heart failure, hepatic cirrhosis, and nephrotic syndrome), and certain renal disorders. By altering renal sodium handling, diuretics influence fluid volume status, blood pressure, and electrolyte balance.
Classification of Diuretics
Diuretics can be classified based on:
- Site of action within the nephron
- Mechanism of action
- Chemical structure
1. Thiazide and Thiazide-like Diuretics:
Thiazide diuretics: Thiazide diuretics are a class of diuretic (water pill) medications that inhibit sodium and chloride reabsorption in the distal convoluted tubule of the in the kidneys. This action increases the excretion of sodium, chloride, and water, thereby reducing blood volume and blood pressure.
Examples: Hydrochlorothiazide, Chlorthalidone
Thiazide-like Diuretics: Thiazide-like diuretics are structurally different from thiazide diuretics but have a similar mechanism of action, affecting the same part of the nephron (distal convoluted tubule). They are often longer-acting and may have different pharmacokinetic properties.
Example: Indapamide, Chlorthalidone, Metolazone.
Site of action: Early distal convoluted tubule (DCT)
Mechanism: Inhibit the Na⁺/Cl⁻ symporter, reducing Na⁺ and Cl⁻ reabsorption.
2. Loop Diuretics:
Loop diuretics are a class of potent diuretic drugs that act on the thick ascending limb of the loop of Henle in the nephron. They inhibit the Na⁺-K⁺-2Cl⁻ symporter, leading to a marked increase in the excretion of sodium, chloride, potassium, calcium, magnesium, and water. This results in a rapid and significant diuretic effect.
Examples: Furosemide, Bumetanide, Torsemide, Ethacrynic acid
Site of action: Thick ascending limb of the loop of Henle
Mechanism: Inhibit Na⁺/K⁺/2Cl⁻ cotransporter → potent natriuresis and diuresis.
3. Potassium-Sparing Diuretics:
Potassium-sparing diuretics are a class of diuretics that help the body get rid of excess sodium and water while retaining potassium. Unlike other diuretics (like thiazides and loop diuretics), they do not cause potassium loss. They act on the distal convoluted tubule and collecting duct of the nephron.
(A) Aldosterone Antagonists: Aldosterone antagonists are a subgroup of potassium-sparing diuretics that block the action of aldosterone at mineralocorticoid receptors in the distal tubules and collecting ducts of the nephron. By doing so, they reduce sodium and water reabsorption and prevent potassium excretion.
Examples: Spironolactone, Eplerenone
Mechanism: Block aldosterone receptors in the distal nephron → decreased Na⁺ reabsorption, K⁺ retention.
(B) Sodium Channel Inhibitors: Sodium channel inhibitors are a subclass of potassium-sparing diuretics that act by blocking epithelial sodium channels (ENaC) in the late distal tubule and collecting duct of the nephron. This inhibits sodium reabsorption and reduces potassium and hydrogen ion excretion, thereby helping retain potassium in the body.
Examples: Amiloride, Triamterene
Mechanism: Directly inhibit epithelial sodium channels (ENaC) in the collecting ducts.
4. Carbonic Anhydrase Inhibitors:
Carbonic anhydrase inhibitors (CAIs) are a class of diuretics that inhibit the enzyme carbonic anhydrase in the proximal convoluted tubule of the nephron. This inhibition decreases the reabsorption of bicarbonate (HCO₃⁻), sodium (Na⁺), and water, leading to increased urinary excretion and mild diuretic action.
Example: Acetazolamide, Dorzolamide, Methazolamide, Brinzolamide
Site: Proximal convoluted tubule
Mechanism: Inhibits carbonic anhydrase → decreased bicarbonate reabsorption → increased Na⁺ and HCO₃⁻ excretion.
5. Osmotic Diuretics:
Osmotic diuretics are pharmacologically inert substances that promote diuresis by increasing the osmolarity of the filtrate in the renal tubules. This action prevents water reabsorption, leading to increased urine output. They act primarily in the proximal tubule and the descending limb of the loop of Henle.
Examples: Mannitol, Urea, Glycerin, Isosorbide
Site: Proximal tubule and descending limb of Henle’s loop
Mechanism: Increases osmotic pressure in renal tubules → inhibits water reabsorption.
6. SGLT2 Inhibitors (Newer class with diuretic effect):
SGLT2 inhibitors (Sodium-Glucose Cotransporter-2 inhibitors) are a newer class of antidiabetic drugs that inhibit glucose reabsorption in the proximal convoluted tubule of the nephron. This results in increased urinary glucose excretion (glucosuria), accompanied by osmotic diuresis, leading to a mild diuretic and natriuretic effect.
Examples: Dapagliflozin, Canagliflozin, Empagliflozin, Ertugliflozin
Site: Proximal tubule
Mechanism: Inhibit sodium-glucose cotransporter-2 → promotes glycosuria and natriuresis.
Mechanism of Action (MOA):
Each class of diuretics has a unique MOA based on which segment of the nephron it acts upon:
| Class | Site of Action | Transporter Affected | Main Effect |
| Thiazides | Early Distal Tubule | Na⁺/Cl⁻ symporter | Moderate Na⁺ and Cl⁻ excretion |
| Loop diuretics | Thick Ascending Loop of Henle | Na⁺/K⁺/2Cl⁻ cotransporter | Potent Na⁺, Cl⁻, and water loss |
| K⁺-sparing (ENaC blockers) | Collecting Duct | Epithelial Na⁺ channels (ENaC) | Weak Na⁺ excretion, K⁺ retention |
| Aldosterone antagonists | Late Distal Tubule/Collecting Duct | Aldosterone receptor | ↓ Na⁺ reabsorption, ↑ K⁺ retention |
| Osmotic diuretics | PCT & LoH | No transporter – osmotic action | H₂O diuresis > Na⁺ excretion |
| Carbonic anhydrase inhibitors | Proximal Convoluted Tubule | Carbonic anhydrase enzyme | Na⁺ & HCO₃⁻ excretion |
| SGLT2 inhibitors | Proximal Tubule | SGLT2 protein | ↓ Glucose and Na⁺ reabsorption |
Therapeutic Uses:
1. Hypertension: Thiazides are the first-line agents (especially in elderly and African populations).They reduce extracellular fluid volume and peripheral vascular resistance.
2. Congestive Heart Failure (CHF): Loop diuretics provide rapid relief of pulmonary and peripheral edema.Spironolactone reduces mortality due to aldosterone antagonism.
3. Edematous States:
- Cirrhosis with ascites
- Nephrotic syndrome
- Chronic renal failure
4. Acute Pulmonary Edema:
- Loop diuretics (e.g., IV furosemide) relieve congestion quickly.
5. Glaucoma:
- Acetazolamide reduces aqueous humor production (carbonic anhydrase inhibition).
- Osmotic diuretics (e.g., mannitol) decrease intraocular pressure acutely.
6. Acute Mountain Sickness:
- Acetazolamide prevents and treats high-altitude symptoms.
7. Cerebral Edema:
- Mannitol reduces intracranial pressure after trauma or neurosurgery.
8. Hypercalcemia:
- Loop diuretics promote calcium excretion.
9. Polycystic Ovary Syndrome (PCOS) and Hirsutism:
- Spironolactone acts as an androgen receptor antagonist.
Adverse Drug Reactions (ADRs):
Thiazides:
- Hypokalemia
- Hyponatremia
- Hypercalcemia
- Hyperuricemia → gout
- Hyperglycemia
- Hyperlipidemia
- Erectile dysfunction
Loop Diuretics:
- Profound hypokalemia and hyponatremia
- Hypocalcemia
- Ototoxicity (dose-dependent and with rapid IV use)
- Dehydration, hypotension
- Metabolic alkalosis
Potassium-Sparing Diuretics:
- Hyperkalemia (especially with ACE inhibitors or ARBs)
- Spironolactone:
- Gynecomastia
- Menstrual irregularities
- Impotence
Carbonic Anhydrase Inhibitors:
- Metabolic acidosis
- Hypokalemia
- Paresthesias
- Renal stone formation
Osmotic Diuretics:
- Transient volume expansion → can worsen heart failure
- Dehydration
- Electrolyte imbalances
SGLT2 Inhibitors:
- Polyuria
- Urinary tract infections
- Euglycemic diabetic ketoacidosis (rare but serious)
Contraindications:
| Class | Contraindications |
| Loop/Thiazide | Severe electrolyte depletion, anuria |
| K⁺-sparing | Hyperkalemia, renal failure |
| Osmotic | Heart failure, pulmonary edema (except mannitol in cerebral edema) |
| Acetazolamide | Hepatic encephalopathy, sulfa allergy |
| SGLT2 inhibitors | Type 1 DM, prone to recurrent UTIs |
Summary Table:
| Diuretic Type | Action Site | Key Features |
| Thiazides | DCT | First-line in HTN, moderate potency |
| Loops | Loop of Henle | High efficacy, used in acute edema |
| K⁺-sparing | Collecting duct | Weak diuresis, used to prevent hypokalemia |
| CA Inhibitors | PCT | Rarely used, glaucoma/mountain sickness |
| Osmotic | PCT, LoH | ICU use: cerebral/pulmonary edema |
| SGLT2 inhibitors | PCT | Diabetic patients, CV and renal benefits |
Conclusion:
Diuretics are among the most frequently prescribed drug classes in clinical medicine due to their versatility, efficacy, and affordability. Understanding the site and mechanism of action is crucial to selecting the appropriate agent for each clinical condition. Though highly beneficial, diuretics must be used judiciously, considering potential electrolyte disturbances, renal function, and drug interactions. Regular monitoring of blood pressure, renal function, and serum electrolytes is necessary to ensure safety and effectiveness.