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Acetazolamide
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Amlodipine
Chlorthalidone
Furosemide
Mannitol
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This patient who presents after a distal radius fracture has both hypertension and osteoporosis. Thiazides may be used as an anti-hypertensive agent and also decreases calcium excretion, which may be beneficial for patients with low bone mineral density. Thiazide diuretics function by inhibiting the sodium chloride co-transporter in the early distal convoluted tubule of the nephron. This inhibition directly results in increased sodium and chloride excretion and also indirectly leads to increased potassium and hydrogen excretion due to the exchange of these metabolites for luminal sodium in the collecting duct of the nephron. Therefore, if increased sodium is delivered to the collecting duct, more of it will be absorbed by this segment resulting in the excretion of potassium and hydrogen. Importantly, calcium absorption in the distal convoluted tubule is increased in patients who take thiazides because the function of a sodium/calcium antiporter at the basolateral surface is augmented by decreased sodium absorption from the apical surface. Thiazide diuretics are used commonly in hypertension, congestive heart failure, calcium nephrolithiasis, idiopathic hypercalciuria, nephrogenic diabetes insipidus, and osteoporosis. Yang et al. studied the effects of thiazide diuretics in patients with osteoporosis. They found that the medication is associated with increased bone mineral density but that this effect was mitigated by episodes of hyponatremia. They recommended being vigilant for signs of hyponatremia in patients who are on thiazide therapy. Incorrect Answers: Answer 1: Acetazolamide is a diuretic that functions by inhibiting carbonic anhydrase. While this drug has also demonstrated possible beneficial effects in osteoporosis, it is not first line for the treatment of hypertension. Instead, it can be used in altitude-related alkalosis. Answer 2: Amlodipine is an antihypertensive agent that functions by inhibiting calcium channels. This medication is commonly used in hypertension but would not be effective at treating osteoporosis. Side effects include peripheral edema. Answer 3: Furosemide is a diuretic that functions by inhibiting the sodium/potassium/chloride cotransporter in the loop of Henle. Furosemide can be used in the treatment of congestive heart failure but increases the excretion of calcium. This is because calcium is absorbed paracellularly in this segment between the tight junctions of loop cells. The driving force behind calcium absorption in this segment is the positive electrical charge in the tubule from the leakage of potassium. This is not a first line anti-hypertensive agent. Answer 4: Mannitol is a diuretic that functions by osmotically retaining water in the nephron. This medication is not first line for either hypertension or osteoporosis but instead can be used in patients with cerebral edema or acute renal failure. Bullet Summary: Thiazide diuretics can be used to treat hypertension and also decrease calcium excretion in patients with osteoporosis.
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