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In some patients, for reasons Post Date: Mon, 13 Oct 2008 18:15:18 +0000 Abnormali-ties of extracellular fluid composition should be sought for and corrected. The administration of additional diuretics may be appropriate. In some patients, for reasons that are not clear, the use of corticosteroids has appeared to restore respon-siveness to a diuretic regimen (Kessler et al, 1962; Jick, 1966). Autor of the post: Undefined In a few patients, for Post Date: Mon, 13 Oct 2008 18:05:17 +0000 As a general rule, patients who are refractory to a diuretic of moderate efficacy, such as the thiazides, will show a more satisfactory response to more pow-erful agents. However, there is great individual vari-ation. In a few patients, for unknown reasons, the less active agents are effective when there is no re-sponse to the more powerful drugs. Autor of the post: Undefined In the initial management Post Date: Mon, 13 Oct 2008 17:45:57 +0000 Use of Multiple Diuretics and Adjuvant Agents. The current availability of many different types of diuretics and many different compounds of the same type has provided the temptation to alter the diuretic regimen at frequent intervals. In the initial management of the edematous subject, when mobilization of edema fluid is the primary goal of therapy, the changing status of the patient warrants appropriate adjustments in dosage schedules and also in the agents selected for use. Autor of the post: Undefined Despite the widespread use Post Date: Mon, 13 Oct 2008 17:32:07 +0000 However, in the chronic management of edema, the best therapeutic re-suits are often correlated with a purposefully constant therapeutic regimen. Minor variations in dosage are warranted on the basis of careful observation.Despite the widespread use of the high-ceiling diuretics for the treatment of chronic edema, especially of cardiac origin, one may properly raise the question of their overuse in situations in which other diuretics, although less effective by conventional standards, might equally well achieve the desired therapeutic goal with less risk of overtreat-ment. Autor of the post: Undefined Urine volume or body weight Post Date: Mon, 13 Oct 2008 17:19:51 +0000 In the severely edematous patient, it is becoming apparent that, if a single diuretic agent proves ineffective, it is proper to use more than one type of diuretic agent. Such a program is most easily supervised if one diuretic is given in a relatively constant dose and the second administered intermittently under careful observation. Urine volume or body weight should be accurately measured so that drug effectiveness does not depend on vague impressions. Autor of the post: Undefined Specific examples of rational concurrent Post Date: Mon, 13 Oct 2008 17:03:21 +0000 When effective, the results of concomitant therapy are usually supra-additive rather than simply additive. Of course, nothing is to be gained by the administration of two drugs of the same type, such as two different thiazides. Specific examples of rational concurrent therapy with diuretics have been cited in the discussion of individual drugs. Autor of the post: Undefined The posterior pituitary antidiuretic hor-mone (ADH) Post Date: Mon, 13 Oct 2008 16:44:32 +0000 It is reemphasized that each agent should be given in an optimally individualized dose and that combinations in a fixed-dose ratio may be less effective unless appropriate for the individual patient.ANTIDIURETIC HORMONE (ADH).The posterior pituitary antidiuretic hor-mone (ADH) and closely related polypep-tides are substances that evoke a graded in-crease in the permeabiUty to water of the mammalian nephron and thereby cause free water to be reabsorbed and conserved. Autor of the post: Undefined Thus, in various species Post Date: Mon, 13 Oct 2008 16:30:26 +0000 Anal-ogous hormones that affect water con-servation and the concentration of solutes in body fluids are found in all vertebrates, even the most primitive. Despite the constancy in the chemical structures of the hormones, the target organs and actions have undergone remarkable adaptive changes in fresh- and salt-water fish, amphibians, and terrestrial vertebrates. Thus, in various species the hor-mones may act by altering blood flow in gill or kidney, sodium transport in skin or blad-der, or permeability of these structures to water and solutes. Autor of the post: Undefined However, the property Post Date: Mon, 13 Oct 2008 16:20:24 +0000 These evolutionary changes have been extensively studied and provide one of the more fascinating chapters in comparative biology {see Sawyer, 1967b, 1972).In primates, presumably including man, the physiological role of ADH is only to alter the permeability of the terminal portions of the renal tubule to water and urea. However, the property of the hormone first detected in posterior pituitary extracts was a vasocon-strictor action {see below). Autor of the post: Undefined The renal excretion of water may Post Date: Mon, 13 Oct 2008 16:07:41 +0000 Unfortunately, the name vasopressin, chosen at that time, per-sists as the official USP designation for the hormone. In this chapter, the term vaso-pressin will be used only in the discussion of natural and synthetic structural analogs and when referring to the preparations of ADH that are available by that name.The renal excretion of water may also be markedly affected by substances (such as nicotine or alcohol) that are capable of di-rectly altering the rate of release of ADH. 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