Potassium-sparing diuretics hyperkalemia with

Pentamidine is structurally similar to amiloride and can cause severe hyperkalemia if co-prescribed with potassium-sparing diuretics (10). This is a particularly important interaction in patients with AIDS. 

Fixed combinations of thiazides and loop diuretics with potassium and of thiazides with beta-blockers serve little useful purpose and can in fact do harm. Combinations of thiazides and loop diuretics with potassium-sparing diuretics serve the needs of the small minority of patients who develop clinically significant hypokalemia when given diuretics alone, or in whom hypokalemia is particularly risky. In fact, these combinations are much too widely used, and since individual needs vary so much there is a spectrum of risk, ranging from hypokalemia to hyperkalemia (SEDA-10, 370) (SEDA-10, 371). 

The hypotensive effects of most antihypertensive dru are increased when administered with diuretics and other antihypertensives. Many dnigp can interact with the antihypertensive drugs and decrease their effectiveness (eg, antidepressants, monoamine oxidase inhibitors, antihistamines, and sympathomimetic bronchodilators). When the ACE inhibitors are administered with the NSAIDs, their antihypertensive effect may be decreased. Absorption of the ACE inhibitors may be decreased when administered with the antacids. Administration of potassium-sparing diuretics or potassium supplements concurrently with the ACE inhibitors may cause hyperkalemia. When the angiotensin II receptor agonists are administered with... 

Hyperkalemia (increase in potassium in the blood), a serious event, may be seen with the administration of potassium-sparing diuretics. Hyperkalemia is most likely to occur in patients with an inadequate fluid intake and urine output, those with diabetes or renal disease tiie elderly, and those who are severely ill. In patients taking spironolactone, gynecomastia (breast enlargement in tiie male) may occur. This reaction appears to be related to both dosage and duration of therapy. The gynecomastia is usually reversible when therapy is discontinued, but in rare instances, some breast enlargement may remain. 

Older adults are particularly prone to fluid volume deficit and electrolyte imbalances (see Display 46-1) while taking a diuretic. The older adult is carefully monitored for hypokalemia (when taking the loop or thiazide diuretic and hyperkalemia (with the potassium-sparing diuretics... 

Medications can increase the risk of hyperkalemia in patients with CKD, including angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers, used for the treatment of proteinuria and hypertension. Potassium-sparing diuretics, used for the treatment of edema and chronic heart failure, can also exacerbate the development of hyperkalemia, and should be used with caution in patients with stage 3 CKD or higher. 

Potassium-sparing diuretics may cause hyperkalemia, especially in patients with chronic kidney disease or diabetes, and in patients receiving concurrent treatment with an ACE inhibitor, ARB, NSAID, or potassium supplement. Eplerenone has an increased risk for hyperkalemia and is contraindicated in patients with impaired renal function or type 2 diabetes with proteinuria. Spironolactone may cause gynecomastia in up to 10% of patients, but this effect occurs rarely with eplerenone. 

ACE inhibitors decrease aldosterone and can increase serum potassium concentrations. Hyperkalemia occurs primarily in patients with chronic kidney disease or diabetes and in those also taking ARBs, NSAIDs, potassium supplements, or potassium-sparing diuretics. 

Oral Severe renal impairment with oliguria or azotemia untreated Addison disease hyperkalemia from any cause adynamia episodica hereditaria acute dehydration heat cramps patients receiving potassium-sparing diuretics or aldosterone-inhibiting agents. 

Contraindications Concurrent use of potassium-sparing diuretics, digitalis toxicity, heat cramps, hyperkalemia, postoperative oliguria, severe burns, severe renal impairment, shock with dehydration or hemolytic reaction, untreated Addison s disease... 

Important drug interactions include those with potassium supplements or potassium-sparing diuretics, which can result in hyperkalemia. Nonsteroidal anti-inflammatory drugs may impair the hypotensive effects of ACE inhibitors by blocking bradykinin-mediated vasodilation, which is at least in part, prostaglandin mediated. 

Cyclosporine has significant nephrotoxicity, and its toxicity can be increased by drug interactions with diltiazem, potassium-sparing diuretics, and other drugs inhibiting CYP3A. Serum creatinine should be closely monitored. Other toxicities include hypertension, hyperkalemia, hepatotoxicity, gingival hyperplasia, and hirsutism. 

Hypertension is a common occurrence with tacrolimus and may require treatment with antihypertensive agents. Since tacrolimus may cause hyperkalemia, potassium-sparing diuretics should be avoided... 

Hypokalemia eventually develops in many patients who are placed on loop diuretics or thiazides. This can often be managed with dietary NaCl restriction. When hypokalemia cannot be managed in this way, or with dietary KC1 supplements, the addition of a potassium-sparing diuretic can significantly lower potassium excretion. While this approach is generally safe, it should be avoided in patients with renal insufficiency in whom life-threatening hyperkalemia can develop in response to potassium-sparing diuretics. 

Alterations in the serum potassium level are hazardous because they may result in cardiac arrhythmias. Drugs that may cause hyperkalemia despite normal renal function include potassium itself, -blockers, digitalis glycosides, potassium-sparing diuretics, and fluoride. Drugs associated with hypokalemia include barium, B-agonists, caffeine, theophylline, and thiazide and loop diuretics. 

Because indomethacin may increase serum potassium concentrations, indomethacin and spironolactone should be administered concomitantly with caution. Potassium-sparing diuretics should be used with caution, and serum potassium should be determined frequently in patients receiving an angiotensin-converting enzyme (ACE) inhibitor (e.g., captopril). Concomitant administration with an ACE inhibitor may increase the risk of hyperkalemia. The dosage of spironolactone should be reduced, or the drug discontinued, as necessary. Patients with renal impairment may be at increased risk of hyperkalemia [65]. 

As a potassium-sparing diuretic, amiloride can cause hyperkalemia (3), even in patients who are taking a potassium-wasting diuretic (4). This effect can be enhanced by concomitant therapy with ACE inhibitors or angioten-sin-II receptor antagonists. In five patients with diabetes melUtus over 50 years of age who were taking an ACE inhibitor the serum potassium rose markedly 8-18 days after the addition of amiloride (5). AH but one had some degree of renal impairment In four cases potassium concentrations were between 9.4 and 11 mmol/1. 

Co-administration of potassium-sparing diuretics with ACE inhibitors can cause severe hyperkalemia (SED-14, 674). In a retrospective study, five patients developed extreme hyperkalemia (9.4-11 mmol/1) within 8-18 days of starting combination therapy with co-amilozide (amiloride -I- hydrochlorothiazide) and an ACE inhibitor (5). 

ACE inhibitors can cause hyperkalemia because they inhibit the release of aldosterone. The effect is usually not significant in patients with normal renal function. However, in patients with impaired kidney function and/or in patients taking potassium supplements (including salt substitutes) or potassium-sparing diuretics, and especially aldosterone antagonists, hyperkalemia can occur. In two cases, hypoaldosteronism with diabetes was implicated (53,54). 

Hyperkalemia has been reported to increase the risk of dysrhythmias in patients taking disopyramide (39), and disopyramide should therefore be used with caution in patients who are taking drugs that can increase body potassium, such as potassium-sparing diuretics and ACE inhibitors. 

Co-administration of potassium-sparing diuretics with ACE inhibitors can cause severe hyperkalemia (SED-14,674). 

The interaction between potassium-sparing diuretics and NSAIDs is well documented (SED-14, 674). The major complications are deterioration of renal function and hjrper-kalemia. The risk associated with the non-selective COX-2 inhibitors is unknown. However, three patients had hyperkalemia (8.5, 5.4, and 5.1 mmol/1) after developing acute renal insufficiency while taking these drugs (8). 

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