Medication Summary
Replacement of electrolytes with chloride salts is the most important mode of therapy for hypochloremic alkalosis. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used in patients with Bartter syndrome. Hydrochloric acid (HCl) and carbonic anhydrase inhibitors may be used in some acute situations.
Electrolytes
Class Summary
Electrolytes are administered to correct disturbances in fluid and electrolyte homoeostasis or acid-base balance. They are also given to reestablish osmotic equilibrium of specific ions.
Potassium chloride (K-Lor, Klor-Con, Micro-K, K-Vescent)
Potassium is essential for transmission of nerve impulses, contraction of cardiac muscle, maintenance of intracellular tonicity, skeletal and smooth muscles, and maintenance of normal renal function. Gradual potassium depletion occurs via renal excretion or gastrointestinal (GI) loss or because of low intake.
Depletion usually results from diuretic therapy, primary or secondary hyperaldosteronism, diabetic ketoacidosis, severe diarrhea (if associated with vomiting), or inadequate replacement during prolonged parenteral nutrition. Potassium depletion sufficient to cause a 1 mEq/L drop in the serum potassium level requires a loss of approximately 100-200 mEq of potassium from the total body store.
Sodium chloride hypertonic
Hypertonic sodium chloride is given to restore sodium ions in patients with restricted oral intake, especially those with hyponatremia states or salt-wasting syndromes.
Nonsteroidal Anti-inflammatory Drugs
Class Summary
NSIADs have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is unknown but may involve inhibition of cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may also play a role, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.
Indomethacin (Indocin)
Indomethacin inhibits prostaglandin synthesis. It is rapidly absorbed and is metabolized in liver via demethylation, deacetylation, and glucuronide conjugation.
Ibuprofen (Motrin, Advil)
Ibuprofen is usually the drug of choice for mild to moderate pain, if no contraindications exist. This drug inhibits inflammatory reactions and pain, probably by decreasing the activity of the enzyme cyclooxygenase, which results in decreased prostaglandin synthesis.
Ketoprofen
Ketoprofen is used to relieve mild to moderate pain and inflammation. Small dosages are initially indicated in small and elderly patients and in those with renal or liver disease. Doses of more than 75 mg do not increase therapeutic effects; therefore, administer high doses with caution, and closely observe patient response.
Naproxen (Anaprox, Naprelan, Naprosyn)
Naproxen is indicated for the relief of mild to moderate pain. This agent acts by inhibiting inflammatory reactions and pain via decreasing the activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.
Carbonic Anhydrase Inhibitors
Class Summary
The major pharmacologic action of agents in this class is noncompetitive inhibition of the enzyme carbonic anhydrase. Carbonic anhydrase is located at the luminal border of cells of the proximal tubule. Urine volume increases with enzyme inhibition (proximal tubule reabsorption of water is reduced by approximately one third), which promotes an alkaline pH. This results in a subsequent decrease in the excretion of titratable acid and ammonia. Increases in urinary excretion of bicarbonate and sodium lead to metabolic acidosis.
Acetazolamide (Diamox Sequels)
Acetazolamide may be used in loop or thiazide diuretic−induced metabolic alkalosis, especially in edematous states.
Acidifying Agents
Class Summary
Consequences of severe metabolic alkalosis include increased susceptibility to ventricular arrhythmia and a left shift of the oxyhemoglobin dissociation curve. HCl is particularly useful in patients with hepatic or renal impairment, which often precludes more standard treatments.
Hydrochloric acid
Intravenous administration of HCl may be indicated in severe metabolic alkalosis (pH >7.55) or when sodium chloride or potassium chloride cannot be administered because of volume overload or advanced renal failure. It may also be indicated if rapid correction of severe metabolic alkalosis is warranted (eg, in cardiac arrhythmia, hepatic encephalopathy, or digoxin toxicity). HCl for IV use is not commercially available and must be extemporaneously compounded from concentrated HCl solution.
Dosing is based on the chloride deficit and base excess. Typically, concentration ranges from 0.1N to 0.15N (ie, H+ concentration of 100-150 mmol/L). Concentrations greater than 0.2N may be associated with an increased risk of hemolysis.
Xanthine Oxidase Inhibitors
Class Summary
Xanthine oxidase inhibitors are effective for treating diuretic-induced hyperuricemia and renal complications resulting in hyperuricemia.
Allopurinol (Zyloprim, Aloprim)
Allopurinol inhibits xanthine oxidase, the enzyme that synthesizes uric acid from hypoxanthine. It reduces synthesis of uric acid without disrupting biosynthesis of vital purines.
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Infant with severe metabolic alkalosis resulting from congenital chloride-losing diarrhea.
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Watery stool from an infant with congenital chloride-losing diarrhea. Chloride level was 205 mmol/L.
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Renal sonogram of an infant with congenital chloride-losing diarrhea showing diffuse sclerosis.
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Sonogram depicting severe nephrocalcinosis in a 2-year-old child with Bartter syndrome.
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Visible bowel loops in an infant with congenital chloride-losing diarrhea.
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Explanation of ion exchange at collecting duct cells in a hypochloremic condition.
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Causes of hypochloremic alkalosis in children.
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Approach to hypochloremic alkalosis.
