A Comprehensive Review on Diuretics: Classification, Mechanism of Action and The Role of Herbal Drugs in Diuretics

Abstract

In clinical practice, loop diuretics are frequently used to control fluid balance and manage high fluid loads. Five diuretic medications—furosemide, torsemide, azosemide, etacrynic acid, and bumetanide—were simultaneously determined by HPLC in this work using a unique quantitative analytical approach for multiple components with a single marker (QAMS)[2]. The osmolarity of blood and urine increases when the kidneys are unable to eliminate water and electrolytes. NPS is treated with diuretics and salt restriction. loop diuretics. Diuretics get rid of water and salt. Medications lower sodium levels. Salt dry arteries BP-lowering. Albumin and diuretics reduce sensitivity[3].The various diuretic classes are described, along with how they work[8]. The diuretic effects of traditional herbal medicines are supported by numerous investigations.[7] Loop diuretics have been the cornerstone of congestion treatment for half a century, despite advancements in disease-modifying therapy[9].Despite the widespread belief that the positive effects of loop diuretics stem from a quick rise in diuresis, a wealth of data from numerous in vitro and in vivo studies has demonstrated that administering furosemide has direct vascular effects, which most likely contribute to its acute clinical effects [11].Diuretics are medications that stimulate urine flow. They are frequently used to treat heart failure, hypertension, and edema. Thiazide diuretics, loop diuretics, potassium-sparing diuretics, osmotic diuretics, and carbonic anhydrase inhibitors are the five groups that typically make up the pharmacological group [12]. The pharmacological profile of several plant medications is also covered in this work, with particular attention paid to the dosage and the bioactive extract's role in the diuretic mechanism [13].Thiazide diuretics are more effective than b-blockers and angiotensin-converting enzyme inhibitors at preventing stroke and are at least as effective at reducing cardiovascular events (CVEs) in patients with hypertension when compared to other drug classes [18].Through the countercurrent multiplier, the kidney's Loop of Henle is responsible for concentrating urine in the body [20].We aimed to ascertain whether thiazide chronotherapy at night results in better control, as has been demonstrated with other drug classes, given the unusual reaction of blood pressure to thiazides in Black individuals[21]. Data supports the usage of chlorthalidone, even though hydrochlorothiazide is the most widely used medication. Another medication with outcome data is indapamide [22]

Keywords

Introduction

Fig no 01: Diagram representation of Diuretics^[30]

General classification of Diuretics:

• High Efficacy Diuretics or Loop Diuretics:- For ex. Furosemide.
• Moderate Efficacy Diuretics: Thiazide: For ex. Chlorothiazide.
• Thiazide Related Agent: For ex. Clopamide. ^[35]
• Lower Efficacy Diuretics :-

1. Potassium Sparing Diuretics: For ex. Amiloride.
2. Carbonic Anhydrous Inhibitor: For ex. Acetazolamide.
3. Osmotic Diuretics: For ex. Mannitol.
4. Methylxanthines: For ex. Theophylline.^[36]

• Newer Drug :-

1. Vasopressin Antagonist: For ex. Tolvaptin.
2. Adenosine A1 Receptor Antagonist: For ex. Rolophyllin^[20].

Table no 01:- Classification of Diuretics[28]

Brief of Diuretics :

Loop diuretics- Stop the sodium-potassium-chloride cotransporter in the thick ascending limb. Because this transporter normally reabsorbs around 25% of the sodium load, inhibiting this pump can result in a considerable increase in the distal tubular sodium concentration, a decrease in interstitial hypertonicity, and a reduction in the quantity of water reabsorption in the collecting duct. This altered sodium and water management results in natriuresis (increased water loss) and diuresis (increased sodium loss). Because they affect the thick ascending limb, which is largely in charge of sodium reabsorption, loop diuretics are incredibly powerful diuretics. These medications not only increase renal blood flow and redistribute renal cortical blood flow, but they also cause the kidneys to produce more prostaglandins^[19].

Thiazide diuretics- These medications work by stopping the kidney's distal convoluted tubule from reabsorbing NaCl. This activity is mediated via the suppression of the sodium chloride cotransporter. Kidney stones, nephrogenic diabetes insipidus, heart failure, hypertension (high blood pressure), and kidney failure are the main conditions treated with these drugs. One example of this class is the drug hydrochlorothiazide ^[40].

Osmotic diuretics -By preventing the reabsorption of water and salt, osmotic diuretics increase the osmolarity of the blood and renal filtrate. These include, for instance, isosorbide and mannitol. reduction of either the cranial or intracranial pressure. treatment for hemorrhagic renal failure. Directly delivering drugs to the brain^[80].

Potassium-sparing diuretics- Certain drugs increase diuresis without lowering potassium levels in the body. One common kind of potassium-saving diuretic is spirolactone. By preventing aldosterone from entering the major cells of the collecting duct and late distal tubule of the nephron, this drug prevents salt and water retention ^[22].

Urinary pH:

The various treatment groups of both extracts produced comparatively alkaline urine, according to a urinary pH assessment. Between the vehicle and extract-treated groups, the NC group had the lowest pH and the standard group had an intermediate pH (7.50). Regarding the trend, rats given aqueous extract had urine with a pH rise from 7.70 (FSAE100) to 8.10 (FSAE400). By comparison, the pH rose from 7.60 (FSME100) to 8.00 (FSME400) after treatment with 80% methanol extract. Rats treated with the higher doses of both extracts (FSAE400 and FSME400) showed a substantial (p<0.05) increase in urine pH when compared to the negative control, according to group comparison ^[70].

Mechanism of Action:

Although diuretics are a diverse class of drugs, certain generalizations may be made. All diuretics, with the exception of mannitol and vasopressin receptor antagonists, work by first preventing sodium from being reabsorbed in different parts of the renal tubules. Carbonic anhydrase inhibitors, loop diuretics, thiazide diuretics, and thiazide-like diuretics are all delivered to their sites of action through the organic acid secretory pathway and enter the tubular lumen^[75]. Aldosterone antagonists, on the other hand, enter the bloodstream and go to the main cells of the cortical collecting duct, their site of action ^[7]. Similar to serum, the primary cationic and anionic osmoles in glomerular filtrate are sodium and chloride, respectively. Filtered NaCl is then reabsorbed into the collecting duct (about 5%), distal convoluted tubule (approximately 10%), loop of Henle (approximately 25%), proximal tubule (approximately 60%), and connecting tubule ^[3].For them to be effective, they must be secreted into the tubular fluid and reach their destination in a concentration that is adequate^[72]. Through the organic acid pathway in the proximal tubule, the process entails enhanced diffusion and, in the case of loop diuretics, thiazides, and the acidic carbonic anhydrase inhibitor acetazolamide, secretion into the tubular fluid^[85]. Since amiloride and triamterene are organic bases, they enter the tubular lumen through the proximal tubule's organic base secretory pathway.^[69] Spironolactone and other aldosterone antagonists are transported to their target location via the blood and basolateral membrane because they work through a cytosolic receptor. Glomerular filtration is restricted if the diuretic is 96% protein bound. There is not enough "free" medication to travel across at once, even in hypoalbuminuria. There are additional factors to take into account, which will be discussed separately along with the diuretic or illness that affects it ^[7].

Side Effect of Diuretics:

Either boosting the glomerular filtration of sodium or decreasing the reabsorption of sodium from the nephron lumen will increase the excretion of sodium together with its associated anions and water. Both mechanisms are frequently involved when a diuresis occurs in an oedematous patient. Glomerular filtration is likely to be affected little or not at all by the majority of primary diuretic agents; however, digoxin and other medications that improve kidney circulation may increase this. Theophylline may have some effect in this way when administered intravenously to humans, as xanthine derivatives are frequently thought to work by increasing the glomerular filtration rate.^[62]These medications, however, have a significant impact elsewhere in the nephron and can function as diuretics without raising glomerular filtration. All of the widely used, clinically beneficial diuretics work at one or more of the locations where salt is eliminated from the nephron lumen. Either increasing the glomerular filtration of sodium or decreasing the reabsorption of sodium from the nephron lumen would result in an increase in the excretion of sodium together with its accompanying anions and water. Both mechanisms are frequently involved when a diuresis occurs in an oedematous patient.^[57] Glomerular filtration is likely to be affected little or not at all by the majority of primary diuretic agents; however, digoxin and other medications that improve kidney circulation may increase this. Theophylline may have some effect in this way when administered intravenously to humans, as xanthine derivatives are frequently thought to work by increasing the glomerular filtration rate. These medications, however, have an important effect elsewhere in the nephron and can function as diuretics without raising glomerular filtration. All of the widely used, clinically beneficial diuretics work at one or more of the locations where salt is eliminated from the nephron lumen^[77].

Usage of Herbs as Diuretics:

Thanks to large pharmaceutical corporations, this herb, which has long been used as a diuretic in India, has become more well-known internationally. Plant medicine has long been used to treat a variety of renal conditions, and it has been discovered that some plants have potent diuretic effects. Research on plants used as diuretics in traditional medicine has increased recently, according to a number of academics, and could be useful in the treatment of hypertension. Hypertension is one of the most dangerous effects of diabetes mellitus ^[14].

Coriander:

Consists of dried, almost ripe fruits from Coriandrum sativum Linn, a plant in the Umbelliferae family. Most likely indigenous to the eastern Mediterranean countries, coriander is a common field weed there. Among the nations that cultivate the plant widely are Bangladesh, China, Russia, Egypt, India, and Europe. Whether dried or fresh, this well-liked herb is commonly used to add flavor and spice to food. Coriander has a fruity, nutty flavor. Their seeds can be crushed or sautéed whole to use in recipes like Thai curries. Alternatively, its leaves can be included into cooked dishes, such as rice. One study looked into coriander seeds' possible diuretic effects ^[60].

Fig no 02: Coriander^[74]

Fennel:

An herb native to the Mediterranean region, fennel grows wild over parts of Europe and India. Fennel is made from the plant Foeniculum vulgare, a member of the Apiaceae family. The bulb, seeds, and leaves are all edible; however, the roots and seeds may have diuretic properties. Roasted fennel is commonly used in bread baking, soups, and pasta recipes. It tastes like licorice or anise ^[65].

Fig no 03: Fennel^[74]

Mangifera indica:

The Anacardiaceous family includes the mango species Mangifera indica. India is where it grows naturally, while other warm climates have seen the introduction of cultivated forms. With a height of up to 100 feet and a circumference that typically spans 12 to 14 feet but can occasionally surpass 20 feet, it is the tallest fruit tree in the world ^[68]. Rats were used by Shree Devi to study the diuretic effects of Mangifera indica bark extract. They use ethanol, ethyl acetate, and a Mangifera indica water extract to examine the effectiveness of the diuretic. The extract was taken orally at a dose of 250 mg per kilogram of body weight. The aqueous extract exhibited a higher Na+/K+ ratio than the ethanol and ethyl acetate extracts, according to the findings of a diuretic study. The aqueous extracts have the strongest diuretic effect when compared to other extracts ^[75].

Fig no 04: Mangifera indica^[74]

Mimosa pudica :

Often referred to as the sleeping plant or the sensitive plant, Mimosa pudica is a creeping annual or perennial herb that is widely grown for its unusual compound leaves that, when touched or disturbed, droop and fold inward to protect the plant's young from predators before emerging again shortly after. The species is indigenous to Central and South America. It grows best in regions with shade, such as beneath bushes or trees ^[75]. Linn. mimosa pudica. Diuretic test using aqueous extract. The Lipchitz test was used to examine leaves in albino rats that were given the right diet. The three test groups received dosages of 100, 200, and 400 mg/kg of aqueous extracts of M. pudica leaves, respectively. In contrast, the standard group received furosemide while the control group received 0.9% NaCl. Urine's biochemistry was examined using calorimetry. The aqueous extract of M. pudica leaves markedly increased electrolyte excretion when given at a dose of 100 mg/kg p.o. Nevertheless, the diuretic action of the test medication does not increase with an increase in dosage ^[14].

Fig no 05: Mimosa pudica^[74]

Horse gram:

It is composed of the dried seeds of the branching, suberect, or twining annual herb Dolichos biflorus, which belongs to the Leguminosae family. Under the name Kulti, it is grown by seeds and vegetative methods and is found all over India. The traditional use of seeds in medicine It goes on to say that after digestion, horse gramme is hot in potency, pungent, astringent, diuretic, and tonic that causes pitta and Rakta disorders. It also relieves cough, kapha and vata disorders, renal calculi, seminal stones, flatulence, rhinitis, induces sweating, lowers body fat, and treats fever ^[15].

Fig no 06: Horse gram^[74]

CONCLUSION:

Diuretics can only ease a symptom. Although the distribution of oedema may have secondary positive effects such improved arterial oxygenation and circulation, they do not eliminate the fundamental cause ^[1]. The review covers the plant's documented behaviors and ethnobotanical uses in addition to its botanical traits, which help in plant identification. Since there haven't been many studies, we advise conducting more to substantiate the claimed activities. Such data is required to support the scientific use of traditional medicines in folklore, and it could even be useful in the development of new medications, therapies, and treatment guidelines ^[80].

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