Michaud Christopher J, Mintus Kendall C
1 Spectrum Health, Grand Rapids, MI, USA.
2 Munson Medical Center, Traverse City, MI, USA.
Ann Pharmacother. 2017 Apr;51(4):286-292. doi: 10.1177/1060028016683971. Epub 2016 Dec 16.
In cases of loop diuretic resistance in the intensive care unit (ICU), recommendations for a specific second-line thiazide agent are lacking.
To compare the effects of intravenous chlorothiazide (CTZ) and enteral metolazone (MET) on urine output (UOP) when added to furosemide monotherapy therapy in critically ill adults.
This was a retrospective cohort study conducted in the medical, surgical, and cardiothoracic ICUs of a quaternary medical center. The primary outcome was change in UOP induced by the study interventions compared with furosemide alone. Secondary outcomes included onset of diuresis, eventual need for hemodialysis, and incidence of adverse events.
A total of 122 patients (58 in CTZ, 64 in MET) were included. When added to furosemide monotherapy, CTZ induced a greater change in UOP at 24 hours compared with MET (2405 vs 1646 mL, respectively; P = 0.01). CTZ also caused a more rapid dieresis: 1463 mL total UOP in the first 6 hours compared with 796 mL in the MET group ( P < 0.01). There were no differences found regarding ICU length of stay, need for renal replacement therapy, or survival to discharge. The CTZ arm required more potassium supplementation to maintain normokalemia (median 100 vs 57 mEq in MET; P = 0.02) and carried a higher cost (mean $97 vs $8, P < 0.01).
Both CTZ and MET induced significant increases in UOP. CTZ induced a greater and more rapid change and was associated with higher cost and greater need for potassium replacement. Randomized controlled trials are needed to establish whether a preferable thiazide diuretic exists in this setting.
在重症监护病房（ICU）中，对于襻利尿剂抵抗的情况，缺乏关于特定二线噻嗪类药物的推荐。
比较在重症成年患者中，静脉注射氯噻嗪（CTZ）和口服美托拉宗（MET）在联合呋塞米单药治疗时对尿量（UOP）的影响。
这是一项在一家四级医疗中心的内科、外科和心胸外科ICU进行的回顾性队列研究。主要结局是与单独使用呋塞米相比，研究干预措施引起的UOP变化。次要结局包括利尿起效时间、最终对血液透析的需求以及不良事件的发生率。
共纳入122例患者（CTZ组58例，MET组64例）。与MET相比，在呋塞米单药治疗基础上加用CTZ时，24小时UOP变化更大（分别为2405 vs 1646 mL；P = 0.01）。CTZ引起利尿更快：前6小时总UOP为1463 mL，而MET组为796 mL（P < 0.01）。在ICU住院时间、肾脏替代治疗需求或出院生存率方面未发现差异。CTZ组需要更多补钾以维持血钾正常（中位数100 vs MET组57 mEq；P = 0.02），且成本更高（平均97美元 vs 8美元，P < 0.01）。
CTZ和MET均能显著增加UOP。CTZ引起的变化更大、更快，且与更高的成本和更多的补钾需求相关。需要进行随机对照试验来确定在这种情况下是否存在更优的噻嗪类利尿剂。
