UA-CONP: Pharmacology (C-NCM106) aidè à vivrè

10. Drugs Affecting the Urinary System

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Pharmacology (C-NCM106) o Bowman’s capsule – funnel like structure; beginning of

Second Year, First Semester, Midterm Reviewer the nephron.
• Appear as a long tubule with a closed end
Outline • Divided into three portions
1. Describe the urinary system and the diseases that affect o Proximal convoluted tubule – reabsorbs ions, water,
its functions. and nutrients; removes toxins and adjusts filtrate Ph
2. Identify pertinent information about the drugs that affect o Loop of Henle (ascending) – reabsorbs sodium and
the urinary system emphasizing on the nursing chloride from the filtrate into the interstitial fluid
considerations. o Loop of Henle (descending) – aquaporins allow water
3. Prepare a concept map that will summarize the drugs
to pass from the filtrate into the interstitial fluid
affecting the urinary system.
o Distal convoluted tubule – selectively secretes and
4. Create a Note that will summarize drugs given for renal
transplant absorbs different ions to maintain blood pH and
5. Apply the knowledge in analyzing a case scenario. electrolyte balance
• Collecting duct – reabsorbs solutes and water from the
A. Overview of the Urinary System and Disorders filtrate
• Nephrons are important in filtering the blood.
Kidneys • The urine contains components that are filtered by the
nephrons that pass through the filtration.
• Bean-shape organs embedded in dorsal part of the
abdomen retroperitoneally
• Consist of three regions
o Outer region (renal cortex), containing foods – filtering
mechanism
o Middle region (renal medulla)
o Inner region (renal pelvis)

Assessing Abnormal
Normal Finding
Kidneys Finding
Perform blunt Normally, no Tenderness of
percussion on the tenderness or sharp pain elicited
kidneys at the pain is elicited or over the CVA
costovertebral reported by the suggests kidney
angles (CVA) over client. The infection
the twelfth rib. examiner senses (pyelonephritis),
only a dull hand. renal calculi, or
hydronephrosis.

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Physiology

CTTO: https://www.cancer.org/cancer/kidney-cancer/about/wh 1. Kidney

at-is-kidney-cancer/_jcr_content/par/textimage/image.img.jpg/1 • Receive and filter a large volume of blood from the renal
580762947948.jpg artery.
• Use tubular absorption and secretion to convert glomerular
Nephron filtrate into urine.
• It is the structural and functional unit of the kidney.
• Over 1 million in each kidney. 2. Nephrons
• Contains: • Use glomeruli to filter blood
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o Glomerular capsule – filters small solutes from the • Flow filtrate through the renal tubules
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blood.
3. Tubules
 UA-CONP: Pharmacology (C-NCM106) aidè à vivrè
10. Drugs Affecting the Urinary System
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• Reabsorb and secrete various substance from the filtrate patient because that will depend on what antibiotic or
• Change filtrate composition and concentration, ultimately antibacterial agent that the patient must receive.
producing urine.
Prostatitis
Note: • Lower UTI in male.
• Glomerular filtration rate (GFR) – depends on the
glomerular capillary permeability, blood pressure and Acute Pyelonephritis
effective filtration rate • Upper UTI, commonly seen in women of childbearing age,
• Kidney cells – secrete renin in response to decreased blood older women, young girls
pressure, blood volume or plasma sodium concentration • Common cause: E. coli.
• Symptoms: chills, high fever, flank pain, pain during
Urinary Tract Disorders urination, urinary frequency and urgency, pyuria
• Management: IV antibiotics (aminoglycosides or
Urinary Tract Infections piperacillin-tazobactam)
• Why females are prone to have UTI than males? o When you already have acute pyelonephritis, oral
o Females have shorter urethra than males (if we are medication will not anymore work. We need now IV
talking about the ascending infection that causes UTI) antibiotics.
o There is a descending UTI than comes from the
Urinary Antiseptics / Anti-Infectives
kidneys, then ureter.
• Prevents bacterial growth in the kidneys and bladder, not
o Usually, we are having lower UTI. Other people
effective for systemic infections
sometimes that UTI is only one part because of the
• Lower dosages – bacteriostatic effect
stasis of the urine. But UTI can be cystitis, urethritis, or
prostatitis. • Higher dosages – bactericidal effect
o As nurses, we have to identify what part causes the
B. Drugs affecting Urinary System
infection.
• Microbial infections of any part of the urinary tract.
1. Urinary Antiseptics / Anti-infectives and Antibiotics
• Upper UTI – pyelonephritis
• Urinary antiseptics / anti-infectives are limited to the
• Lower UTI – cystitis, urethritis, prostatitis
treatment of UTIs.
• Common management: nitrofurantoin and trimethoprim-
• Drug action occurs in the renal tubule and bladder, where it
sulfamethoxazole
is effective in reducing bacterial growth.
• Uncomplicated UTIs – fluoroquinolones (levofloxacin)
• A urinalysis, as well as a culture and sensitivity test, is
Acute Cystitis usually performed before the initiation of drug therapy.
• Because of hygienic measures. • As bactericidal agents, these drugs have the potential to
cause superinfections.
• Frequently occurs in female patients (shorter urethra);
common in women of childbearing age, older women and • The urinary antiseptics / antiinfectives are fosfomycin
tromethamine, nitrofurantoin, methenamine hippurate,
younger girls.
trimethoprim, ertapenem, and the fluoroquinolones.
• Common caused: E. coli.
• Symptoms: pain, burning on urination and urinary frequency Nitrofurantoin
and urgency • First prescribed to treat UTIs in 1953.
• Need for urine culture before antibiotic is given. • Bacteriostatic or bactericidal, depending on the drug
o To identify what microorganism causes the infection. If dosage, and it is effective against many gram-positive and
it is a bacterium, we can treat it. Because that will gram-negative organisms, especially E. coli.
depend on what antibiotic or antibacterial agent that the o Bactericidal
patient must receive. Remember that we have ▪ Directly eradicates / kills the invading
medication that is designed for gram positive and microorganism.
gram-negative bacteria in order to have better ▪ The suffix “cidal” it means kill.
management. ▪ It kills the microorganism.
o When we still do not know what causes the disease, ▪ Not all antibacterial agent is bactericidal, some of
we can give broad spectrum antibiotics. If we already them are bacteriostatic.
know what is the microorganism, we can use now o Bacteriostatic
narrow spectrum. This is better if we already know what ▪ Substances that inhibit the growth of bacteria;
microorganism causes the infection because it is more weakens the pathogen sufficiently to allow the
effective and active than the broad spectrum because patient’s immune system to complete the recovery
this is specific for that particular microorganism. process.
o Because when we see the different antibiotics, it is ▪ It inhibits the growth of the bacteria
indicated: indication: for gram-positive microorganism ▪ The role of the human body: to continue killing the
or for gram-negative microorganism. This means that
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microorganism. It is needed to have strong

we must know what causes a disorder or disease of the
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resistance because the WBCs or antibodies are

 UA-CONP: Pharmacology (C-NCM106) aidè à vivrè
10. Drugs Affecting the Urinary System
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the ones who will continue to kill the Trimethoprim and Trimethoprim – Sulfamethoxazole
microorganism or bacteria. • Cotrimoxazole is combination of trimethoprim and
▪ It leaves now the role of the host body to continue sulfamethoxazole. This is a sulfa drug. The generic drug is
killing it. The bacteriostatic only inhibits the growth cotrimoxazole.
and it weaken the pathogen. o This drug combination produces slow acting.
▪ There is antibacterial agent that are both • Used alone for the treatment of UTIs, but usually used in
bactericidal and bacteriostatic. combination with a sulfonamide, sulfamethoxazole (the
• Given in prophylaxis as prophylactic use (bacteriostatic) combined generic preparation is called TMP-SMZ), to
• High dose – bactericidal effect – gram-positive and gram- prevent the occurrence of trimethoprim-resistant
negative organisms such as E. coli, Staphylococcus organisms.
aureus, streptococci, and Neisseria and Klebsiella species. • This drug combination produces slow acting bactericidal
• Indication: used to treat cystitis and UTIs. effects against most gram-positive and gram-negative
• Pharmacokinetics: well absorbed from the gastrointestinal organisms, especially strains of S. aureus, including
(GI) tract; moderately protein bound, excreted in the urine; methicillin-resistant S. aureus (MRSA), and also Shigella
short half-life 20minutes; accumulate in the serum with and Proteus species.
urinary dysfunction. • Indication: treatment and prevention of acute and chronic
• Usually taken with food to decrease GI distress (anorexia, UTIs.
nausea, vomiting, abdominal pain, and diarrhea) • Half-life is 6 to 12 hours and longer in patients with renal
• Decrease absorption occurs when the drug is taken with dysfunction
antacids. • Side effects: GI symptoms (anorexia, nausea, and vomiting
o Do not give it with antacids. and skin problems such as rash and pruritus)
• Onset and duration of action are unknown; peak action
occurs 30 minutes after absorption. Flouroquinolones (Quinolones)
• Contact health care provider if sudden onset of dyspnea, • Fluoroquinolones are one of the groups of urinary
chest pain, cough, fever, and chills develop. antibacterial that are effective against strains of
• Side effects: Side effects of nitrofurantoin include GI Acinetobacter, Chlamydia, Clostridium, Klebsiella,
disturbances such as anorexia, nausea, vomiting, diarrhea, Staphylococcus, and Streptococcus species that cause
and abdominal pain and pulmonary reactions such as lower UTIs
dyspnea, chest pain, and cough. • E.g.: ciprofloxacin, ofloxacin, and levofloxacin.
• Drug interactions: antacids decrease nitrofurantoin o Common drugs that are given for patients having UTI.
absorption Not all antibiotics are given. Remember that we have
antibiotics that are intended for UTI.
Methanamine • Reserved for patients who have no alternative treatment
• Bactericidal effect when the urine pH is less than 5.5 related to its harsh adverse reactions of tendon rupture,
(acidic). peripheral neuropathy, central nervous system effects,
o When there is an UTI, it must be treated because there and exacerbation of myasthenia gravis.
are patients undergoing hemodialysis because of • Need to decrease the dosage if there is renal dysfunction.
recurrent UTI until such time the kidney cannot work • Half-lives is 2 to 8 hours, but prolonged in patients with renal
anymore. dysfunction
o Normal result of urinalysis: look that the normal pH of • Used for caution for complicated UTIs and acute
the urine: 4.6-8. pyelonephritis and levofloxacin is only used for
o The urine pH when the patient has UTI: 7.5 or greater uncomplicated UTIs when no other options are
(basic). available.
o In order for the methenamine to be effective, the urine • Side effects of ciprofloxacin and ofloxacin: headaches,
pH must be less than 5.5. photosensitivity, dizziness, nausea, vomiting, diarrhea,
• Effective against gram-positive and gram-negative visual impairment, rash, and pruritus
organisms, especially E. coli, Enterococcus and Proteus • Serious adverse reactions: peripheral neuropathy,
species, and Pseudomonas aeruginosa. tendinitis, and tendon rupture
• Indication: chronic UTIs. • Fluoroquinolones may exacerbate muscle weakness in
• Absorbed readily from the GI tract, and approximately patients with myasthenia gravis.
90% of the drug is excreted in the urine unchanged. • Direct patients to stop taking fluoroquinolones immediately
• Methenamine forms ammonia and formaldehyde in acid if experiencing serious adverse reactions and notify health
urine – need to acidify the urine to exert a bactericidal care provider.
action.
• To decrease the urine pH: Cranberry juice (several 8- 2. Urinary Analgesics
ounce glasses per day), ascorbic acid, and ammonium ▪ Analgesics are given for the relief of pain. We give
chloride analgesics for patients having UTI because in UTI, there is
• Side effects: nausea, dysuria, hematuria, and crystalluria pain.
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• Drug interactions: NaHCO3 inhibits the action of

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methenamine; Methenamine + sulfonamides = crystalluria Phenazopyridine

 UA-CONP: Pharmacology (C-NCM106) aidè à vivrè
10. Drugs Affecting the Urinary System
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• Phenazopyridine hydrochloride, an azo dye, and • The condition of the patient who take these drugs are that
dimethyl sulfoxide (also called DMSO) are urinary they always urinate. These drugs will make the patient not
analgesics that are used to relieve the urinary pain, burning to urinate.
sensation, frequency, and urgency of urination that are • Urinary tract spasms resulting from infection or injury can
symptomatic of cystitis. be relieved with antispasmodics that have a direct action on
• Phenazopyridine (Pyridium) can cause GI disturbances the smooth muscles of the urinary tract.
such as abdominal cramps, hemolytic anemia, and renal • Antispasmodics/antimuscarinics/anticholinergics frequently
and hepatic dysfunction. have side effects including blurred vision, headache,
• The urine becomes a harmless reddish orange because dizziness, dry mouth, constipation, and tachycardia.
of the phenazopyridine dye. • The patient taking these drugs should be taught to report
o The anti-TB drug that causes red-orange urine is urinary retention, severe dizziness, blurred vision,
rifampicin because of the dye. We instruct our patients palpitations, and confusion.
that is okay, it is part of the drug. o Because this drug will inhibit the urination of the
• Phenazopyridine can alter the glucose urine test (Clinitest), patient.
therefore a blood test should be used to monitor glucose o The inhibition of urination of the patient will be the result
levels. of the anticholinergic, anti-parasympathetic nervous
• Dimethyl sulfoxide may cause a garlic-like taste and skin system. The effect now will be on the sympathetic
hyperpigmentation. nervous system.
• Maybe used with antibiotics and should discontinue after 2
days of antibiotic use Urinary Antispasmodics
• Side effect: headache, vertigo, nausea, GI distress • Hyoscyamine, mirabegron, oxybutynin Cl, and flavoxate
• Adverse effects: anaphylaxis, methemoglobinemia, renal HCl.
and hepatic failure • Mechanism of action: relaxes smooth muscles of the
urinary tract → ↓ bladder muscle spasm to prevent the
Nursing Consideration patient from urinating.
A. Ensure renal function before administering. o The patient is not taking this drug every day.
a. The patient has the ability to urinate. o The patient takes this drug every other day as
B. Use only as analgesic. prescribed by the physician.
C. Take with food. o It is a prescription medication.
D. Do not double the dose if dose is missed. • Used to manage the disorders of the lower urinary tract
E. Report to physician if notices yellowing of the eyes. associated with hypermotility; (dysuria, urgency, nocturia,
a. Medical term for yellow eyes is icteric sclera. Probably suprapubic pain, frequency and incontinence)
one factor would be the affection of the liver of the • Side effects: headache, insomnia, drowsiness, dizziness,
patient. confusion, excitement, blurred vision, dry mouth, GI
distress, urinary retention, urinary hesitancy.
3. Urinary Stimulants • Contraindication: urinary or GI obstruction, glaucoma,
• When there is a lesion in the nervous system, it is evolving obstructive breathing, severe ulcerative colitis, myasthenia
and while it is evolving, the surrounding parts function can gravis, hypersensitivity to anticholinergics, paralytic ileus,
have a problem. unstable CV status
• When bladder function is decreased or lost as a result of: • Administration consideration: administer 1 hour before
o Neurogenic bladder (a dysfunction caused by a lesion antacids or antidiarrheals
of the nervous system • Drug interaction: amantadine increases adverse
o Spinal cord injury (paraplegia, hemiplegia) anticholinergic effects; phenothiazines or haloperidol will
o Severe head injury, a parasympathomimetic may be result in decreased antipsychotic effect; antacids and
used to stimulate micturition (urination). antidiarrheals result in decreased absorption of
• Remember that the problem of the patient is that it hyoscyamine; additive effect with another anticholinergic
cannot urinate, so we need stimulants to make him or drug
her urinate. • Antispasmodics have the same effects as antimuscarinics,
• Drug of choice – bethanechol chloride – urinary stimulant agents that block parasympathetic nerve impulses;
• It is a direct-acting parasympathomimetic. parasympatholytic; and anticholinergics
o Remember that the parasympathomimetic has an
opposite effect which is sympathomimetic. Antimuscarinic / Anticholinergic
o If it is parasympathomimetic, the function of GI and GU • E.g.: Tolterodine tartrate, trospium chloride, solifenacin
increases. succinate, darifenacin hydrobromide
• Mechanism of action: increase bladder tone by increasing • Used to control an overactive bladder, which causes
tone of the detrusor urinal muscle, which produces a frequency in urination
contraction strong enough to stimulate urination. • Effect: decrease urgency and urinary incontinence
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4. Urinary Antispasmodics / Antimuscarinics / 5. Drugs Used to Treat Benign Prostatic Hyperplasia

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Anticholinergics (BPH)
• Doxazosin, Tamsulosin, Terazosin, Finasteride (Proscar)
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o Finasteride is used for male pattern baldness. o When patients with chronic renal failure undergo CBC,
o Finasteride is contraindicated to patient who is you will see that they have a low level of hemoglobin.
pregnant because it has an effect on the fetus. And now, we need this drug because the kidney has a
• Mechanism of action: block alpha 1 receptors in the role in the production of RBC.
prostate leading to relaxation of smooth muscles, improving o Hematopoietic growth factor is given to stimulate the
urine flow and decreasing BPH symptoms RBC production.
• Used to increase urine flow and decrease symptoms of • Common medication: epoetin alfa (Epogen, Procrit) SQ /
BPH IV 300 to 500 IU/kg/dose 3 times/week.
• Administration Consideration: o MWF or TTHS
o Do not handle crushed tablets if pregnant o Administered in the belly because it contains a lot of
o Not indicated for females or pediatric use adipose tissue.
o Postural effects may occur 2 to 6 hours after dose • Administration consideration:
o If treatment is interrupted for several days, restart o Initial effects can be seen within 1 to 2 weeks
medication at initial dose o Hematocrit reaches normal levels (20 to 33%) in 2 to 3
• Side effects: impotence, decrease volume of ejaculate, weeks
decreased libido, asthenia, dizziness, postural hypotension, o Do not shake solution
nasal congestion, peripheral edema, diarrhea o IV administration: epoetin alfa may be given undiluted
• Contraindication: hypersensitivity and caution in clients by direct IV as a bolus dose
with impaired hepatic function ▪ Usually, Epogen is in pre-filled syringe.
• Drug Interaction: Use cautiously with warfarin; cimetidine • Side effects: hypertension, headache – most common
may decrease clearance; do not use with alpha adrenergic side effect, seizure, iron deficiency, sweating
blockers • Adverse effects: thrombocytosis, clotting of AV fistula,
o Cimetidine classification is histamine 2 receptor bone pain, arthralgias, headache.
blockers / antagonist. Given for patient with ulcer.
Nursing Considerations
Nursing Consideration A. Blood pressure may rise during early therapy as hematocrit
A. Change position slowly increases; notify physician of a rapid rise in hematocrit
B. Avoid activities requiring alertness greater than 4 points in 2 weeks.
C. Take medications same time each day B. Do not give with any other drug solution.
D. Advise women who are or may become pregnant not to C. Use only one dose per vial, do not re-enter vial.
handle crushed tablets of finasteride related to risk to male D. Client may require additional heparin during dialysis to
fetus prevent clotting of the vascular access.
E. Male with sexual partners should not be pregnant to
avoid exposing his partner to his semen. 8. Drugs to Prevent Organ Rejection

6. Drugs Used to Treat Renal Failure Cyclosporine (Neoral)

• Mechanism of action: the primary focus of pharmacologic • It is an immunosuppressant.
management of renal failure is to restore and maintain o Because there is a new organ that is placed in the
renal perfusion and to eliminate drugs that are directly body, the body will not see this one as foreign. To fight
nephrotoxic. this, we give immunosuppressant.
• Diuretics to improve urinary outflow and antihypertensive. • Acts on T-lymphocytes to suppress production of
o Always remember that the kidney has a big role in interleukin-2
maintaining the blood pressure of the patient related to • Used to prevent rejection of allogenic kidney transplant.
the RAAS because it will cause vasoconstriction, o In allogenic kidney transplant, the donor comes from
retention of sodium and water. relatives, twins, brothers/sisters, or other people?
• Dopaminergic receptors cause vasodilation in the renal, ▪ Other people that is why the body will see it as a
mesenteric, coronary and intracerebral vascular beds foreign.
• Used to increase urine flow • Oral administration is preferred.
• Blood levels should be monitored frequently.
Dopamine • Administer prednisone concurrently.
• Increase renal perfusion – 2 to 5mcg/kg/min o Remember that prednisone is a steroid, it lowers the
• Raise blood pressure – 50mcg/kg/min immune system.
o And antihypertensive and diuretic agents. • Client should be instructed to monitor signs of infections.
o Because if you are taking immunosuppressants, the
7. Hematopoietic Growth Factor immune system will be lowered down. The person now
• Kidney has the effect on the production of RBC. So when is prone to acquire different diseases,
the kidney has a problem, we need hematopoietic growth • Grapefruit juice can raise cyclosporine levels, thus
factor. increasing risk of toxicity.
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• Mechanism of action: used to stimulate RBC production o We have to limit the intake of grapefruit juices.
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• Reverse anemia associated with chronic renal failure.

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• Mix the concentrated medication solution with milk,

chocolate milk, or orange juice before administration
• Side effects: nausea, vomiting, hypertension, tremor,
hirsutism, depression, anaphylactic shock
• Given 4 to 12 hours before transplant and continued for 1
to 2 weeks after surgery.

Azathioprine (Imuran)
• Cytotoxic drug.
• Suppresses cell mediated and humoral immunity.
• Used with cyclosporine to help suppress transplant
rejection.
• Can cause neutropenia.
• Side effects: nausea, vomiting, bone marrow depression,
agranulocytosis, secondary infection.

Muromonab – CD3 (Orthoclone OKT3)

• Antibody
• Used to prevent acute allograft rejection of kidney
transplants
• Side effect: nausea, vomiting, chest pain, dyspnea
• Dose: 5mg/day administered in less than 1 minute for 10 to
14 days

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