Brater Algorithm

While maintaining other diuretics, switch loop agent to continuous infusion

FIGURE 28-7 "Brater's algorithm" for diuretic therapy of chronic renal failure, nephrotic syndrome, congestive heart failure, and cirrhosis. Follow algorithm until adequate response is achieved. If adequate response is not obtained, advance to the next step. For illustrative purposes, the thiazide diuretic used in Brater's algorithm is hydrochlorothiazide (HCTZ). An alternative thiazide-type diuretic may be substituted with appropriate dosage adjustment so as to be pharmacologically equivalent to the recommended dose of HCTZ. Do not combine two K+-sparing diuretics because of the risk of hyperkalemia. CrCl indicates creatinine clearance in mL/min, and ceiling dose refers to the smallest dose of diuretic that produces a near-maximal effect. Ceiling doses of loop diuretics and dosing regimens for continuous intravenous infusions of loop diuretics are disease-state-specific; see Brater (1998) for recommended dosages. Doses are for adults only.

drugs of the same type. Thiazide diuretics with significant proximal tubular effects (e.g., metola-zone) are particularly well suited for sequential blockade when coadministered with a loop diuretic. Reducing salt intake will diminish postdiuretic Na+ retention that can nullify previous increases in Na+ excretion.Diuretic dosing shortly before eating will provide effective drug concentrations in the tubular lumen when the salt load is highest.

For a complete Bibliographical listing see Goodman & Gilman's The Pharmacological Basis of Therapeutics, 11th ed., or Goodman & Gilman Online at

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