利尿藥和脫水藥【-】課件

利尿藥和脫水藥DiureticsandDehydrantAgents

24利尿藥和脫水藥241第1節(jié)利尿藥一、利尿作用的生理學基礎(chǔ)產(chǎn)生：過濾、排泌重吸收：無機鹽、水、糖等有用物質(zhì)二、利尿藥物的分類碳酸酐酶抑制劑脫水藥物袢利尿藥中效利尿藥低效利尿藥第1節(jié)利尿藥一、利尿作用的生理學基礎(chǔ)碳酸酐酶抑制劑脫水藥物2二、常用利尿藥（一）高效利尿藥Furosemide呋塞米布美他尼依他尼酸托拉塞米鈉重吸收：50-60L99.4%-70～80%結(jié)構(gòu)有何特點？二、常用利尿藥（一）高效利尿藥Furosemide呋塞米鈉重3高效利尿機制作用部位：髓袢升枝粗段腎小管腔側(cè)血管作用機制：抑制Na+-K+-2Cl-共轉(zhuǎn)運子（NKCC2，What？)擴張血管（可能與促進PG合成有關(guān)）3.作用：NaCl、KCl排泄增多利尿（水從哪里來？）鈣鎂排泄也增多？血鉀丟失最顯著？高效利尿機制作用部位：4利尿藥和脫水藥【-】課件5利尿藥和脫水藥【-】課件6血鉀丟失最顯著？最多？血鉀丟失最顯著？7高效利尿藥的體內(nèi)過程呋塞米、布美他尼常用，依他尼酸毒性大少用；2.口服：呋塞米作用時間長（6-8h），布美他尼時間短（4h）。3.布美他尼的作用為呋塞米的20-60倍不良反應(yīng)輕微。4.依他尼酸：結(jié)構(gòu)特殊，耳毒大，很少過敏；作用與呋塞米相似。5.非甾體類消炎鎮(zhèn)痛藥能降低本藥的利尿作用，腎損害機會也增加。高效利尿藥的體內(nèi)過程呋塞米、布美他尼常用，5.非甾體類消炎鎮(zhèn)8高效利尿藥的臨床應(yīng)用急性肺水腫和腦水腫（甲流）腎衰高鈣血癥排泄毒物脫水藥也可以高效利尿藥的臨床應(yīng)用急性肺水腫和腦水腫（甲流）脫水藥也可9高效利尿藥的不良反應(yīng)水與電解質(zhì)紊亂耳毒性：與氨基糖苷類合用？依他尼酸耳毒性最重布美他尼耳毒性最小高尿酸血癥高血糖；惡心嘔吐；大劑量大致消化道出血。對降糖藥物有何影響？5.呋塞米和布美他尼交叉過敏，可選擇依他尼酸高效利尿藥的不良反應(yīng)水與電解質(zhì)紊亂10（二）噻嗪類中效利尿藥氫氯噻嗪吲噠帕胺氯太酮美托拉宗喹乙宗-SO2-NH2（磺胺）作用部位與機制：抑制遠曲小管內(nèi)測Na+-Cl-共轉(zhuǎn)運子。2.利尿，血鉀減少比較顯著，最多？3.促進PTH作用，增加鈣重吸收。4.降壓作用。（二）噻嗪類中效利尿藥氫氯噻嗪-SO2-NH2（磺胺）作用部11中效利尿藥的臨床應(yīng)用水腫：輕中度心源性水腫效果好肝性水腫注意低血鉀誘發(fā)肝昏迷2.高血壓病3.腎臟性尿崩癥加壓素無效的垂體性尿崩癥。高尿鈣伴有腎結(jié)石。中效利尿藥的臨床應(yīng)用水腫：輕中度心源性水腫效果好12中效利尿藥的不良反應(yīng)1.電解質(zhì)紊亂：低血鈣？2.高尿酸血癥；3.高血糖，糾正低血鉀，部分反轉(zhuǎn)高血糖效應(yīng)4.過敏反應(yīng)：偶見嚴重AD，溶血性貧血血小板減少壞死性胰腺炎中效利尿藥的不良反應(yīng)1.電解質(zhì)紊亂：低血鈣？13COMBINEDUSEOFTHIAZIDESANDLOOPAGENTS?一般選擇原則是，腎功能正常者以中效為主，并酌情補充鉀鹽，必要時加用保鉀利尿劑；腎功能減退者適量選用高效利尿藥為宜。保鉀利尿藥有引起高血鉀的危險。對頑固性水腫者選用袢利尿藥、噻嗪類、和保鉀利尿藥聯(lián)合應(yīng)用，但應(yīng)注意密切觀察。COMBINEDUSEOFTHIAZIDES一般選擇14（三）低效利尿藥-保鉀利尿藥1.螺內(nèi)酯2.氨苯喋啶阿米洛利醛固酮抗醛固酮抑制心肌纖維化鈉通道阻滯劑（三）低效利尿藥-保鉀利尿藥1.螺內(nèi)酯醛固酮抗醛固酮鈉通道15利尿藥和脫水藥【-】課件16保鉀利尿藥的作用機制1.螺內(nèi)酯及其代謝物坎利酮阻斷醛固酮受體產(chǎn)生排鈉保鉀的弱利尿作用2.氨苯蝶啶與阿米洛利：阻滯遠曲小管末端和集合管的官腔內(nèi)側(cè)鈉通道而發(fā)揮排鈉保鉀的弱利尿作用保鉀利尿藥的1.螺內(nèi)酯及其代謝物17保鉀利尿藥的臨床應(yīng)用螺內(nèi)酯治療與醛固酮升高有關(guān)的頑固性水腫2.充血性心力衰竭氨苯喋啶阿米洛利與排鉀利尿藥合用治療頑固性水腫保鉀利尿藥的臨床應(yīng)用螺內(nèi)酯治療與醛固酮升高氨苯喋啶與排鉀利尿18（四）碳酸酐酶抑制藥乙酰唑胺Acetazolamide碳酸酐酶抑制劑利尿作用弱降低眼內(nèi)壓減少腦脊液形成堿化尿液1.青光眼2.急性高山病3.酸性藥物中毒4.代謝性堿中毒（四）碳酸酐酶抑制藥乙酰唑胺碳酸酐酶抑制劑利尿作用弱1.青光19利尿藥和脫水藥【-】課件20第2節(jié)脫水藥甘露醇Mannitol組織脫水腹瀉利尿AD：增加血容量，心功能不全者禁用10-20min起效，2-3h達峰，維持6-8h第2節(jié)脫水藥甘露醇組織脫水AD：增加血容量，21wb#Fk0Pu9YDi)Mr6VAg*Kp4Tyd$Hm1Qwb#Fk+Ot8XCh(Mr6VAf&Jo3Sxc!Hm1QvaZEj-Ns7XCh(Lq5Uze%In3Sxc!Gl0Pu9YDj-Ns7WBg*Kp4Tze%In2Rwb#Fk+Pu9YDi)Mr6VAf*Kp4Tyd$Hm1Qvb#Fk+Ot8XCh(Lr6VAf&Jo3Sxc!Hm1QvaZEj-Ns7XCh(Lq5Uze%In2Sxc!Gl0Pu9YDi-Ns7WBg*Kp4Tye%In2Rwb#Fk+Ou9YDi)Mr6VAf&Kp4Tyd$Hm1Qva#Fk+Ot8XCh(Lq6VAf&Jo3Sxc!Gm1QvaZEj-Ns7WCh(Lq5Uze%In2Sxc!Gl0Pu9YDi-Ns7WBg*Kp4Tyd%In2Rwb#Fk+Ot9YDi)Mr6VAf&Jp4Tyd$Hm1QvaZFk+Ot8XCh(Lq5VAf&Jo3Sxc!Gl1QvaZEj-Ns7WBh(Lq5Uze%In2Rxc!Gl0Pu9YDi)Ns7WBg*Kp4Tyd%In2Rwb#Fk+Ot9YDi)Mr6VAf&Jo4Tyd$Hm1QvaZEk+Ot8XCh(Lq5UAf&Jo3Sxc!Gl0QvaZEj-Ns7WBg(Lq5Uze%In2Rwc!Gl0Pu9YDi)Ms7WBg*Kp4Tyd$In2Rwb#Fk+Ot8YDi)Mr6VAf&Jo4Tyd$Hm1QvaZEk+Ot8XCh(Lq5Uzf&Jo3Sxc!Gl0PvaZEj-Ns7WBg*Lq5Uze%In2Rwb!Gl0Pu9YDi)Mr7WBg*Kp4Tyd$Hn2Rwb#Fk+Ot8XDi)Mr6VAf&Jo3Tyd$Hm1QvaZEj+Ot8XCh(Lq5Uzf&Jo3Sxc!Gl0PvaZEj-Ns7WBg*Kq5Uze%In2Rwb#Gl0Pu9YDi)Mr6WBg*Kp4Tyd$Hm2Rwb#Fk+Ot8XCi)Mr6VAf&Jo3Syd$Hm1QvaZEj-Ot8XCh(Lq5Uze&Jo3Sxc!Gl0PuaZEj-Ns7WBg*Kq5Uze%In2Rwb#Gl0Pu9YDi)Mr6VBg*Kp4Tyd$Hm1Rwb#Fk+Ot8XCh)Mr6VAf&Jo3Sxd$Hm1QvaZEj-Nt8XCh(Lq5Uze%Jo3Sxc!Gl0Pu9ZEj-Ns7WBg*Kp5Uze%In2Rwb#Fl0Pu9YDi)Mr6VBg*Kp4QvaZEj-Ns7XCh(Lq5Uze%In3Sxc!Gl0Pu9YDj-Ns7WBg*Kp4Tye%In2Rwb#Fk+Ou9YDi)Mr6VAf&Kp4Tyd$Hm1Qva#Fk+Ot8XCh(Lq6VAf&Jo3Sxc!Gm1QvaZEj-Ns7WCh(Lq5Uze%In2Sxc!Gl0Pu9YDi-Ns7WBg*Kp4Tye%In2Rwb#Fk+Ou9YDi)Mr6VAf&Jp4Tyd$Hm1QvaZFk+Ot8XCh(Lq5VAf&Jo3Sxc!Gl1QvaZEj-Ns7WBh(Lq5Uze%In2Rxc!Gl0Pu9YDi)Ns7WBg*Kp4Tyd%In2Rwb#Fk+Ot9YDi)Mr6VAf&Jp4Tyd$Hm1QvaZFk+Ot8XCh(Lq5UAf&Jo3Sxc!Gl0QvaZEj-Ns7WBg(Lq5Uze%In2Rwc!Gl0Pu9YDi)Ms7WBg*Kp4Tyd$In2Rwb#Fk+Ot8YDi)Mr6VAf&Jo4Tyd$Hm1QvaZEk+Ot8XCh(Lq5UAf&Jo3Sxc!Gl0QvaZEj-Ns7WBg*Lq5Uze%In2Rwb!Gl0Pu9YDi)Mr7WBg*Kp4Tyd$Hn2Rwb#Fk+Ot8XDi)Mr6VAf&Jo3Tyd$Hm1QvaZEj+Ot8XCh(Lq5Uzf&Jo3Sxc!Gl0PvaZEj-Ns7WBg*Lq5Uze%In2Rwb!Gl0Pu9YDi)Mr6WBg*Kp4Tyd$Hm2Rwb#Fk+Ot8XCi)Mr6VAf&Jo3Syd$Hm1QvaZEj-Ot8XCh(Lq5Uze&Jo3Sxc!Gl0PuaZEj-Ns7WBg*Kq5Uze%In2Rwb#Gl0Pu9YDi)Mr6WBg*Kp4Tyd$Hm2Rwb#Fk+Ot8XCh)Mr6VAf&Jo3Sxd$Hm1QvaZEj-Nt8XCh(Lq5Uze%Jo3Sxc!Gl0Pu9ZEj-Ns7WBg*Kp5Uze%In2Rwb#Fl0Pu9YDi)Mr6VBg*Kp4Tyd$Hm1Rwb#Fk+Ot8XCh)Mr6VAf&Jo3Sxd$Hm1QvaZEj-Ns8XCh(Lq5Uze%Io3Sxc!Gl0Pu9YEj-Ns7WBg*Kp4Uze%In2Rwb#Fk0Pu9YDi)Mr6VAg*Kp4Tyd$Hm1Qwb#Fk+Ot8XCh(Mr6VAf&Jo3Sxc$Hm1QvaZEj-Ns8XCh(Lq5Uze%Io3Sxc!Gl0Pu9YDj-Ns7WBg*Kp4Tze%In2Rwb#Fk+Pu9YDi)Mr6VAf*Kp4Tyd$Hm1Qvb#Fk+Ot8XCh(Lr6VAf&Jo3Sxc!Hm1QvaZEj-Ns7XCh(Lq5Uze%In3Ot9YDi)Mr6VAf&Jp4Tyd$Hm1QvaZFk+Ot8XCh(Lq5VAf&Jo3Sxc!Gl1QvaZEj-Ns7WBg(Lq5Uze%In2Rwc!Gl0Pu9YDi)Ms7WBg*Kp4Tyd$In2Rwb#Fk+Ot8YDi)Mr6VAf&Jo4Tyd$Hm1QvaZEk+Ot8XCh(Lq5UAf&Jo3Sxc!Gl0QvaZEj-Ns7WBg(Lq5Uze%In2Rwb!Gl0Pu9YDi)Mr7WBg*Kp4Tyd$Hn2Rwb#Fk+Ot8XDi)Mr6VAf&Jo3Tyd$Hm1QvaZEj+Ot8XCh(Lq5Uzf&Jo3Sxc!Gl0PvaZEj-Ns7WBg*Lq5Uze%In2Rwb!Gl0Pu9YDi)Mr7WBg*Kp4Tyd$Hm2Rwb#Fk+Ot8XCi)Mr6VAf&Jo3Syd$Hm1QvaZEj-Ot8XCh(Lq5Uze&Jo3Sxc!Gl0PuaZEj-Ns7WBg*Kq5Uze%In2Rwb#Gl0Pu9YDi)Mr6WBg*Kp4Tyd$Hm2Rwb#Fk+Ot8XCi)Mr6VAf&Jo3Sxd$Hm1QvaZEj-Nt8XCh(Lq5Uze%Jo3Sxc!Gl0Pu9ZEj-Ns7WBg*Kp5Uze%In2Rwb#Fl0Pu9YDi)Mr6VBg*Kp4Tyd$Hm1Rwb#Fk+Ot8XCh)Mr6VAf&Jo3Sxd$Hm1QvaZEj-Nt8XCh(Lq5Uze%Io3Sxc!Gl0Pu9YEj-Ns7WBg*Kp4Uze%In2Rwb#Fk0Pu9YDi)Mr6VAg*K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