Site and mechanism of the action of diuretics

Systemic pharmacological interventions for Ménière's disease

BACKGROUND

Ménière's disease is a condition that causes recurrent episodes of vertigo, associated with hearing loss and tinnitus. A number of pharmacological interventions have been used in the management of this condition, including betahistine, diuretics, antiviral medications and corticosteroids. The underlying cause of Ménière's disease is unknown, as is the way in which these treatments may work. The efficacy of these different interventions at preventing vertigo attacks, and their associated symptoms, is currently unclear.

OBJECTIVES

To evaluate the benefits and harms of systemic pharmacological interventions versus placebo or no treatment in people with Ménière's disease.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 14 September 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs in adults with definite or probable Ménière's disease comparing betahistine, diuretics, antihistamines, antivirals or systemic corticosteroids with either placebo or no treatment. We excluded studies with follow-up of less than three months, or with a cross-over design (unless data from the first phase of the study could be identified).  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were: 1) improvement in vertigo (assessed as a dichotomous outcome - improved or not improved), 2) change in vertigo (assessed as a continuous outcome, with a score on a numerical scale) and 3) serious adverse events. Our secondary outcomes were: 4) disease-specific health-related quality of life, 5) change in hearing, 6) change in tinnitus and 7) other adverse effects. We considered outcomes reported at three time points: 3 to < 6 months, 6 to ≤ 12 months and > 12 months. We used GRADE to assess the certainty of evidence for each outcome.  MAIN RESULTS: We included 10 studies with a total of 848 participants. The studies evaluated the following interventions: betahistine, diuretics, antivirals and corticosteroids. We did not identify any evidence on antihistamines.  Betahistine Seven RCTs (548 participants) addressed this comparison. However, we were unable to conduct any meta-analyses for our primary outcomes as not all outcomes were considered by every study, and studies that did report the same outcome used different time points for follow-up, or assessed the outcome using different methods. Therefore, we were unable to draw meaningful conclusions from the numerical results. Some data were available for each of our primary outcomes, but the evidence was low- or very low-certainty throughout. One study reported on the outcome 'improvement in vertigo' at 6 to ≤ 12 months, and another study reported this outcome at > 12 months. Four studies reported on the change in vertigo, but again all used different methods of assessment (vertigo frequency, or a global score of vertigo severity) or different time points. A single study reported on serious adverse events.  Diuretics Two RCTs addressed this comparison. One considered the use of isosorbide (220 participants), and the other used a combination of amiloride hydrochloride and hydrochlorothiazide (80 participants). Again, we were unable to conduct any meta-analyses for our primary outcomes, as only one study reported on the outcome 'improvement in vertigo' (at 6 to ≤ 12 months), one study reported on change in vertigo (at 3 to < 6 months) and neither study assessed serious adverse events. Therefore, we were unable to draw meaningful conclusions from the numerical results. The evidence was all very low-certainty.  Other pharmacological interventions We also identified one study that assessed antivirals (24 participants), and one study that assessed corticosteroids (16 participants). The evidence for these interventions was all very low-certainty. Again, serious adverse events were not considered by either study.

AUTHORS' CONCLUSIONS

The evidence for systemic pharmacological interventions for Ménière's disease is very uncertain. There are few RCTs that compare these interventions to placebo or no treatment, and the evidence that is currently available from these studies is of low or very low certainty. This means that we have very low confidence that the effects reported are accurate estimates of the true effect of these interventions. Consensus on the appropriate outcomes to measure in studies of Ménière's disease is needed (i.e. a core outcome set) in order to guide future studies in this area and enable meta-analyses of the results. This must include appropriate consideration of the potential harms of treatment, as well as the benefits.

Quantification of Carbonic Anhydrase Inhibitors and Metabolites in Urine and Hair of Patients and Their Relatives

Simple Summary

Carbonic anhydrase inhibitors such as dorzolamide, brinzolamide, and acetazolamide are prescription drugs prohibited in sports. Detecting these substances and their biomarkers of consumption in urine and hair is crucial to documenting misuse in doping. We quantified dorzolamide, brinzolamide, acetazolamide, and their metabolites in the urine and hair of 88 patients under treatment, and samples of the patients’ relatives were analyzed to assess potential for accidental exposure. We found that cutoff concentrations of urinary dorzolamide and brinzolamide are necessary to preclude false positives due to contamination or passive exposure. Additionally, we reported the first concentrations of brinzolamide in hair.

Abstract

Carbonic anhydrase inhibitors (CAIs) are prescription drugs also used in doping to dilute urine samples and tamper with urinalyses. Dorzolamide, brinzolamide, and acetazolamide are prohibited by the World Anti-Doping Agency. Detecting CAIs and their metabolites in biological samples is crucial to documenting misuse in doping. We quantified dorzolamide, brinzolamide, acetazolamide, and their metabolites in the urine and hair of 88 patients under treatment for ocular hypertension or glaucoma. Samples of the patients’ relatives were analyzed to assess potential for accidental exposure. After washing, 25 mg hair was incubated with an acidic buffer at 100 °C for 1 h. After cooling and centrifugation, the supernatant was analyzed by ultra-high-performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS). Urine (100 μL) was diluted and centrifuged before UHPLC-MS/MS analysis. Run time was 8 min through a reverse-phase column with a mobile phase gradient. MS/MS analysis was performed in a multiple-reaction monitoring mode after positive electrospray ionization. Median urinary concentration was 245 ng/mL (IQR: 116.2–501 ng/mL) for dorzolamide, 81.1 ng/mL (IQR: 35.9–125.3 ng/mL) for N-deethyl-dorzolamide, 0.77 ng/mL (IQR: 0.64 ng/mL–0.84 ng/mL) for N-acetyl-dorzolamide, 38.9 ng/mL (IQR: 20.4–79.2 ng/mL) for brinzolamide, and 72.8 ng/mL (IQR: 20.7–437.3 ng/mL) for acetazolamide. Median hair concentration was 0.48 ng/mg (IQR: 0.1–0.98 ng/mg) for dorzolamide, 0.07 ng/mg (IQR: 0.06–0.08 ng/mg) for N-deethyl-dorzolamide, 0.40 ng/mL (IQR: 0.13–1.95 ng/mL) for brinzolamide. Acetazolamide was detected in only one hair sample. Dorzolamide and brinzolamide were detected in the urine of three and one relatives, respectively. Cutoff concentrations of urinary dorzolamide and brinzolamide are necessary to preclude false positives due to contamination or passive exposure. We reported the first concentrations of brinzolamide in hair.

Screening and elucidation of fragmentations of 23 diuretics in dietary supplements using UHPLC-Q-Orbitrap

Diuretics are used to treat the edematous state in cases of renal insufficiency, nephrotic syndrome, liver cirrhosis, and heart failure. These compounds are used by athletes to lose weight and are included in the list of prohibited substances by the World Anti-Doping Agency. They are also used by obese and overweight people for losing weight, and there are a number of recent reports on the contamination of dietary supplements with diuretics. Due to the alluring online marketing and blogging, there is an extensive misuse of products that are illegally adulterated with diuretics, which has seriously increased health risks. Therefore, it is essential to develop an analytical method for the detection of adulterants in such substances. In this study, 23 diuretics, categorized into four groups, namely, thiazide diuretics (e.g., bendroflumethiazide), loop diuretics (e.g., bumetanide), potassium-sparing diuretics (e.g., amiloride), and carbonic anhydrase inhibitors (e.g., acetazolamide), were analyzed using ultrahigh-performance liquid chromatography-quadrupole orbitrap (UHPLC-Q-Orbitrap). Their fragmentation was elucidated based on the MS/MS data. The 124 products were screened by the UHPLC-Q-Orbitrap (LC-HRMS) method, and the confirmed compounds were quantitated by a previously established LC-MS/MS method. Approximately 5% of the samples were found to be illegally contaminated with diuretics at a concentration of 0.051-162 mg/g. The high selectivity and sensitivity of the UHPLC-Q-Orbitrap (LC-HRMS) method, in combination with the established fragmentation, offer a new approach for the rapid and accurate screening of diuretics in adulterated products, which would be ultimately beneficial for the public health.

Cardiorenal Syndrome: Role of Arginine Vasopressin and Vaptans in Heart Failure

Heart and kidney failure continued to be of increasing prevalence in today's society, and their comorbidity has synergistic effect on the morbidity and mortality of patients. Cardiorenal syndrome (CRS) is a complex disease with multifactorial pathophysiology. Better understanding of this pathophysiological network is crucial for the successful intervention to prevent advancement of the disease process. One of the major factors in this process is neurohormonal activation, predominantly involving renin-angiotensin-aldosterone system (RAAS) and arginine vasopressin (AVP). Heart failure causes reduced cardiac output/cardiac index (CO/CI) and fall in renal perfusion pressures resulting in activation of baroreceptors and RAAS, respectively. Activated baroreceptors and RAAS stimulate the release of AVP (non-osmotic pathway), which acts on V₂ receptors located in the renal collecting ducts, causing fluid retention and deterioration of heart failure. Effective blockade of AVP action on V₂ receptors has emerged as a potential treatment option in volume overload conditions especially in the setting of hyponatremia. Vasopressin receptor antagonists (VRAs), such as vaptans, are potent aquaretics causing electrolyte-free water diuresis without significant electrolyte abnormalities. Vaptans are useful in hypervolemic hyponatremic conditions like heart failure and liver cirrhosis, and euvolemic hyponatremic conditions like syndrome of inappropriate anti-diuretic hormone secretion. Tolvaptan and conivaptan are pharmaceutical agents that are available for the treatment of these conditions.

Study on diuretic activity of saffron (stigma of Crocus sativus L.) Aqueous extract in rat

Saffron is the most expensive spice in the world and consists of the dried stigmas of Crocus sativus L. It is used as food coloring and flavoring in food industry and traditional cooking and also in folk medicine as antispasmodic, carminative, stomachic, expectorant, aphrodisiac and cardiotonic. The present study has evaluated the diuretic activity of aqueous extract of dried saffron (stigma of Crocussativus) in rat. Aqueous extracts of saffron were administered to experimental rats orally as doses of 60, 120 and 240 mg/kg body weight (BW) and compared with hydrochlorothiazide (10 mg/kg B.W., intraperitoneally), a potent diuretic as positive control and normal saline solution as placebo for control group. The measured parameters for diuretic activity were total urine volume, urine electrolytes concentration such as sodium and potassium, creatinine and urea concentration. The treated rats with aqueous extract of saffron as doses of 120 and 240 mg/kg BW showed higher urine output when compared to the control group. Also, it has shown a significant dose-dependent increase in the excretion of electrolytes when compared to the control group. Our findings proved the diuretic activity of saffron which is used in traditional medicine, it can be an effective and safe strategy for related dysfunction. Also further studies are needed to identify the mechanisms of action, probably other effects and interactions with other medicines.

A quantitative method of evaluating the diuretic response to furosemide in rats

Furosemide effects are usually evaluated by measuring the urinary excretion rate of Na+ (UVNa) in humans. In the present study, however, UVNa showed a nonlinear relationship with urine flow rate after intravenous injection of furosemide in rats. In contrast, when the urinary excretion rate of (Na+ + K+) (UVNa + K) was plotted against the urine flow rate, a linear regression line was observed, with small interindividual variations in normal rats and in rats with uranyl nitrate-induced acute renal failure (ARF). Piretanide, a loop diuretic, also showed a similar relationship, while other types of diuretics revealed different slope values for the relationship. Although the urinary excretion rate of Cl- (UVCl) vs UVNa + K is expected to show a linear relationship in normal rats, the correlation coefficient of the linear regression line was smaller than that of the urine flow rate vs UVNa + K. Further, the slope of UVCl vs UVNa + K was slightly different in ARF rats. Therefore, UVNa + K provides a better quantitative measure of diuretic response to loop diuretics than UVNa or UVCl.

Regulation of renal peripheral benzodiazepine receptors by anion transport inhibitors

The in vitro and in vivo regulation of [3H]Ro 5-4864 binding to peripheral benzodiazepine receptors (PBR) by ion transport/exchange inhibitors was studied in the kidney. The potencies of 9-anthroic acid, furosemide, bumetanide, hydrochlorothiazide and SITS as inhibitors of [3H]Ro 5-4864 binding to renal membranes were consistent with their actions as anion transport inhibitors (Ki approximately equal to 30 - 130 microM). In contrast, spironolactone, amiloride, acetazolamide, and ouabain were less potent (Ki = 100-1000 microM). Administration of furosemide to rats for five days resulted in a profound diuresis (approximately equal to 350% increase in urine volume) accompanied by a significant increase in PBR density (43%) that was apparent by the fifth day of treatment. Administration of hydrochlorothiazide or Ro 5-4864 for five days also caused diuresis and increased renal PBR density. Both the diuresis and increased density of PBR produced by Ro 5-4864 were blocked by coadministration of PK 11195, which alone had no effect on either PBR density or urine volume. The equilibrium binding constants of [3H]Ro 5-4864 to cardiac membranes were unaffected by administration of any of these drugs. These findings suggest that renal PBR may be selectively modulated in vivo and in vitro by administration of ion transport/exchange inhibitors.

The influence of dietary potassium on the renal tubular effect of hydrochlorothiazide in the rat

The influence of dietary potassium on the natriuretic effect of hydrochlorothiazide was investigated in conscious rats which had access to 0.46 M NaCl solution; the intake of saline was used as an index of the natriuresis. Control rats drank very little saline (less than 1 mmol 24 h-1), whereas animals given hydrochlorothiazide in the food (35 mg kg-1 dry weight) increased their saline intake to approximately 10 mmol 24 h-1. In a third group of rats, on a high-potassium diet (360 mmol kg-1 dry weight vs 60 mmol kg-1 dry weight), the same dose of hydrochlorothiazide increased the saline intake to only 2 mmol 24 h-1. In order to investigate the renal mechanisms involved in these effects, animals were anaesthetized and prepared for micropuncture. Collections were made from late surface convolutions of proximal tubules and from early and late regions of distal tubules. Total glomerular filtration rate, single-nephron filtration rate, and the delivery of sodium to the end of the proximal tubule and to the beginning of the distal tubule were similar in the three groups of rats. In rats on a normal diet, hydrochlorothiazide treatment was associated with an increased delivery of sodium to the end of the distal tubule. No such increase was seen in thiazide-treated rats on a high potassium intake. It is concluded that a high potassium intake reduces the natriuretic effect of hydrochlorothiazide as a result of interference with thiazide-induced inhibition of sodium reabsorption in the distal tubule. The effect of potassium does not depend on changes in sodium handling in other nephron segments. The possible roles of aldosterone and distal tubular potassium secretion in mediating this effect are discussed.

Effects of chlorothiazide, furosemide and PTH on Na+ and Ca2+ handling in isolated perfused kidneys of the spontaneously hypertensive rat

The role of the kidney in a disturbed calcium metabolism in spontaneously hypertensive rats (SHR) was investigated. The hemodynamics of isolated perfused SHR kidneys were not basically altered compared to Wistar-Kyoto (WKY) control kidneys. Renal calcium handling by isolated perfused WKY and SHR kidneys at 12 weeks of age was not significantly different. In addition, the effects of chlorothiazide and furosemide on renal calcium handling were studied in isolated perfused kidneys from both rat strains. Both diuretics increased glomerular filtration rate, diuresis and excretion of sodium and calcium. However, both diuretics stimulated diuresis and calcium excretion significantly less in SHR than in WKY kidneys. The calciuric action of chlorothiazide was completely abolished by administration of human-parathyroidhormone (hPTH), while the natriuric effect was unchanged by hPTH. This observation suggests that a hypocalciuric action of chlorothiazide 'in vivo' is possibly mediated by PTH. Our study suggests that the kidney is not responsible for the disturbance in calcium metabolism in SHR. A surprising finding is that the SHR kidney was less responsive to the diuretics furosemide and chlorothiazide than the kidney of the WKY control.

Disposition of bumetanide in the isolated perfused rat kidney: effects of probenecid and dose response

The isolated perfused rat kidney was used to study the pharmacokinetic-pharmacodynamic relation of bumetanide and furosemide. Diuresis, as indicated by the concomitant increase in urine volume and fractional excretion of sodium, was produced with both drugs. The action of furosemide was dependent on a high clearance resulting from combined glomerular filtration and tubular secretion. The site of furosemide action was the luminal side of the nephron and a large amount of drug was required in the tubular lumen to produce diuresis. A bidirectional transport of bumetanide was indicated. Although tubular secretion of bumetanide was demonstrated, the action of bumetanide was not dependent on secretion and the highest response was achieved when bumetanide was filtered and partially reabsorbed. The lack of dependency on secretion to produce a response may be indicative of bumetanide reaching its site of action from the luminal as well as the vascular side of the nephron. In the isolated perfused rat kidney, although both drugs had the same pharmacodynamic endpoint, each drug had a different pharmacokinetic profile that characterized its response.