Mroczek W J
Angiology. 1976 Jun;27(6):358-69. doi: 10.1177/000331977602700604.
The development of modern pharmacologic diuretic agents has revolutionized the therapy of arterial hypertension. The diuretics currently available are easily administered orally, are effective in the presence of alkalosis or acidosis, are non-toxic and have a low incidence of side effects which are readily circumvented or treated. Loop diuretics such as furosemide have the capacity to be effective in patients with diminished renal function or clinical situations that have a powerful stimulus to sodium retention. In clinical circumstances when renal potassium loss is to be prevented such as in patients receiving digitalis, the addition of a potassium-sparing diuretic to either a thiazide or furosemide will achieve the clinical goal of providing an effective diuresis while inhibiting potassium excretion. The mechanism of antihypertensive activity of the diuretic agents appears to be the reduction of extracellular fluid volumes and plasma volumes. Hence, the clinical dictum that to be effective as an antihypertensive agent, diuretics should be administered in diuretic doses. Besides being the cornerstone of initial antihypertensive therapy, diuretics also play an important role in antihypertensive therapy of patients with moderate to severe hypertension who are receiving potent antihypertensive drugs of the vasodilator or sympatholytic class of compounds. Indeed, one of the most important steps in the successful therapy of these patients receiving multiple drugs, is the re-assessment of the diuretic agent. The sodium retention and consequent fluid volume expansion associated with the administration of these potent antihypertensive agents may often cause these patients to develop apparent drug resistance since the thiazide diuretics are not potent enough to counteract the powerful stimulus to sodium retention caused by these antihypertensive agents. The re-evaluation of the diuretic agent at this point will usually necessitate the substitution of furosemide for thiazide or the doubling of the dose of the present loop diuretic. A working knowledge of the physiology of urine formation and the sites of action of currently available diuretic agents will enable the clinician to tailor the diuretic agent to the clinical circumstances of an individual patient and allow the clinician to rationally select a diuretic for the treatment of arterial hypertension.
现代药理学利尿剂的发展彻底改变了动脉高血压的治疗方法。目前可用的利尿剂易于口服给药，在碱中毒或酸中毒情况下均有效，无毒且副作用发生率低，这些副作用很容易规避或治疗。呋塞米等袢利尿剂对肾功能减退或有强烈钠潴留刺激的临床情况的患者也有效。在临床情况下，如在接受洋地黄治疗的患者中要预防肾脏钾流失，在噻嗪类利尿剂或呋塞米中添加保钾利尿剂将实现有效利尿同时抑制钾排泄的临床目标。利尿剂的降压活性机制似乎是细胞外液量和血浆量的减少。因此，临床格言认为，作为一种降压药要有效，利尿剂应以利尿剂量给药。除了是初始降压治疗的基石外，利尿剂在接受血管扩张剂或交感神经阻滞剂类强效降压药治疗的中重度高血压患者的降压治疗中也起着重要作用。事实上，在这些接受多种药物治疗的患者成功治疗中最重要的步骤之一，是重新评估利尿剂。与这些强效降压药给药相关的钠潴留以及随之而来的液体量扩张，可能经常导致这些患者出现明显的耐药性，因为噻嗪类利尿剂不足以抵消这些降压药引起的强大钠潴留刺激。此时对利尿剂的重新评估通常需要用呋塞米替代噻嗪类利尿剂或使当前袢利尿剂的剂量加倍。对尿液形成生理学以及当前可用利尿剂作用部位的实用知识，将使临床医生能够根据个体患者的临床情况调整利尿剂，并使临床医生能够合理选择用于治疗动脉高血压的利尿剂。
