Diuretics

What Kind of Drug Is It?

The main goal of diuretic therapy is to get rid of extra fluids in the body. Diuretics reduce bodily fluids by increasing the production of urine. Diuretic drugs are used to treat high blood pressure, congestive heart failure (CHF), and various other conditions that cause the body to retain, or hold in, water. CHF occurs when the heart is unable to circulate, or pump, the blood throughout the body with sufficient force.

Overview

Diuretics are a class of drugs that increase urine output. That means that users not only urinate more often, they urinate in greater amounts than usual. The main medical uses for diuretics are the treatment of high blood pressure and congestive heart failure.

Because diuretics cause an overall water weight loss, they are often abused by individuals with eating disorders such as anorexia (pronounced ah-nuh-REK-see-uh) and bulimia (pronounced bull-EEM-eeh-yuh). Anorexia is a severe disorder characterized by an intense fear of gaining weight, a refusal to eat, a distorted sense of self-image, and excessive weight loss. Bulimia is a disorder that involves long periods of bingeing on food, followed by self-induced vomiting and abuse of laxatives. The words anorexia and bulimia are both taken from the Greek language. Anorexia means "no appetite" and bulimia means "great hunger."

Official Drug Name: The three main groups of diuretics (die-er-EH-tiks) discussed in this entry are: 1) the loop diuretics, 2) the potassium-sparing diuretics, and 3) the thiazide (THY-uhzide) diuretics. Loop diuretics include bumetanide (byoo-MEH-tuh-nide; Bumex), furosemide (fur-OH-seh-mide; Lasix), and torsemide (TORE-seh-mide; Demadex). Potassium-sparing diuretics include amiloride hydrochloride (am-ILL-ohr-ide high-droh-KLOR-ide; Midamor), spironolactone (speer-oh-noh-LACK-tone; Aldactone), and triamterene (try-AM-tuh-reen; Dyrenium). Thiazide (and thiazide-like) diuretics include chlorothiazide (KLOR-oh-THY-uh-zide; Diurigen, Diuril), chlorthalidone (klor-THAL-ih-doan; Hygroton, Thalitone), hydrochlorothiazide (HIGH-droh-KLOR-oh-THY-uh-zide; Dichlotride, Esidrix, Ezide, Hydrochlor, Hydro-D, Hydro-DIURIL, Hydro-Par, and Microzide), indapamide (inn-DAH-puh-mide; Lozol), and metolazone (meh-TOE-luh-zone; Diulo, Mykrox, Zaroxolyn).

Also Known As: Water pills

Drug Classifications: Not scheduled

Diuretics are also abused by athletes who are trying to "make weight" for certain classes of competition. Oftentimes, the use of diuretics can help athletes, such as weightlifters, lose just enough—perhaps an extra pound or so—to remain in their chosen weight class. This practice is illegal in sporting competition, however. Diuretics are considered banned substances according to the International Olympic Committee (IOC), the United States Anti-Doping Agency (USADA), the World Anti-Doping Agency (WADA), the National Collegiate Athletic Association (NCAA), and a number of other national and international sporting authorities.

William Withering's Work on Diuretics

The name diuretic comes from a Greek term meaning "to urinate." This type of drug first gained acceptance in the medical community when eighteenth-century British physician William Withering (1741–1799) created digitalis (dij-ih-TAL-us) from the dried leaves of the foxglove plant (Digitalis purpurea). Digitalis gives the heart muscle a boost, making its contractions stronger and faster.

Digitalis also acts as a diuretic. In With-ering's time, it became a popular treatment for dropsy (DROP-see), an old-fashioned term for edema. People with edema often have swollen feet, ankles, and lower legs due to water buildup in their tissues. Fluid retention in the tissues of the body can be very dangerous. It is frequently related to congestive heart failure, which can be deadly. As of 2005, digitalis-type drugs were still being used in the treatment of heart failure. By strengthening the contractions of the heart muscle, digitalis helps pump excess fluids throughout the body. When the heart works more efficiently, fluids are less likely to pool, or accumulate, in the feet and legs.

Breakthroughs in Diuretic Research

In 1957, researchers John Baer, Karl Beyer, James Sprague, and Frederick Novello formulated the drug chlorothiazide (KLOR-oh-THY-uh-zide), the first of the thiazide diuretics. It was a pioneering achievement in medicine. Chlorothiazide was the first safe and effective long-term treatment for patients with high blood pressure and heart failure. All four scientists received the Albert and Mary Lasker Foundation Special Public Health Award for 1975 for their work on diuretic drug compounds. According to the Lasker Foundation Web site, "Such compounds are now universally accepted as a primary treatment for these conditions."

The next class of diuretic drugs to be developed were the so-called "loop diuretics." They take their name from the fact that they work on a specific part of the kidney known as the loop of henle. Loop diuretics are the most powerful of all diuretics. The first one to appear on the market was furosemide (Lasix) in 1965. Loop diuretics were hailed as a major advance in the treatment of congestive heart failure.

It was around this time that over-the-counter diuretics first became available. Pamabrom (Pamprin), a medication that relieves the fluid retention and bloating associated with a woman's menstrual cycle, is still available without a prescription. There are also certain dietary supplements that may have diuretic action as a side effect, but have a different primary purpose. For example, the supplement creatine promotes fluid loss with regular use. (A separate entry on creatine is available in this encyclopedia.)

What Is It Made Of?

Diuretics are medicines with complex chemical structures. For example, the chemical formula for chlorothiazide, the best known of the thiazide diuretics, is C₇H₆ClN₃O₄S₂.

How Is It Taken?

Diuretics are most commonly available in pill form. In a hospital setting, they may be injected directly into a patient's veins. Certain diuretics used to control pressure on the eyeball may be administered in eye drop form. Some diuretics are consumed naturally in foods, including various fruits, vegetables, and herbs.

Are There Any Medical Reasons for Taking This Substance?

Diuretics are typically used to treat high blood pressure, congestive heart failure, edema, and other conditions that cause the body to retain excess fluids. In addition to their traditional uses, diuretics show promise in the treatment of several other

medical conditions, including osteoporosis, heart attack, and stroke.

Usage Trends

The 2004 edition of The Pill Book and the 2005 edition of the Nursing Spectrum Drug Handbook list the loop diuretic furosemide (Lasix) among the top ten most commonly prescribed drugs in the United States. Not far behind were the thiazide diuretic hydrochlorothiazide and the potassium-sparing diuretic triamterene, both of which landed in the top twenty.

Cheap but Effective Prescription Drugs

Lawrence K. Altman reported in the New York Times that "traditional water pills, or diuretics, are superior to newer, more expensive drugs in lowering high blood pressure and preventing its serious and often fatal complications." In 2002, a New Jersey-based study was conducted involving more than 42,000 men and women of varied ethnic backgrounds age fifty-five and older. The results showed that diuretics were found more effective in lowering the participants' blood pressure than the trendier—and extremely costly—new classes of blood pressure drugs. In follow-up reports published in 2005, researchers suggested that thiazide diuretics, in particular, are also helpful in preventing heart attacks and strokes.

In addition, several sources, including the 2003 Rotterdam Study, have shown that thiazide diuretics "may reduce bone loss by reducing the amount of calcium excreted in the urine," reported Eric Nagourney in the New York Times. Thiazide diuretics seem to protect the elderly against hip fractures, a common and potentially life-threatening ailment among older people. "The benefit was most pronounced in people over eighty," noted Nagourney.

Abusing Diuretics to Lose Weight

Although diuretics have legitimate uses, some people abuse the drugs. The most widespread abuses of diuretics appear among: 1) individuals suffering from eating disorders; and 2) athletes attempting to keep their weight down for sporting competitions.

According to the National Institute of Mental Health (NIMH), up to 3.7 percent of females suffer from anorexia, and up to 4.2 percent of females suffer from bulimia at some point in their lives. Anorexia involves self-starvation in an effort to keep off weight. Bulimia involves a cycle of bingeing and purging, meaning people eat massive amounts of food in a single sitting and then attempt to rid themselves of the huge caloric intake before it can be digested. Bulimics purge the food through self-induced vomiting, laxative use, and diuretics.

Males generally develop eating disorders less frequently than females. However, as of 2005, the percentage of males with eating disorders was on the rise. In addition, the National Eating Disorders Association (NEDA) reported that patients with either anorexia or bulimia frequently "develop the other eating disorder" within five to fifteen years of developing the first. In other words, a person with anorexia may end up with bulimia and a person with bulimia may end up with anorexia. This shift in disorders, according to NEDA president Doug Bunnell, helps "remind clinicians, patients, and families that these disorders are complicated."

Blood Pressure Facts

The following statistics were cited in reports on a study of diuretics funded by the National Heart, Lung and Blood Institute, the National Institute on Aging, and the Robert Wood Johnson Foundation.

• High blood pressure affects about 50 million people in the United States, and the risk increases with age.
• Half of all Americans over the age of sixty have high blood pressure.
• One-third of Americans over the age of sixty have both high blood pressure and diabetes, a serious disorder affecting the level of sugars in the blood.

The Sports Connection

Diuretic use and eating disorders in sports and professional athletics are growing concerns both in the United States and abroad. Jockeys, swimmers, and gymnasts, for instance, compete under conditions where "smaller" is considered "better." Weight loss among these and other athletes may be encouraged by coaches. Female athletes, in particular, often develop eating disorders and unhealthy weight-loss practices, including diuretic abuse. This puts them at a higher risk for osteoporosis and interrupting their menstrual cycle.

Sports such as weightlifting, wrestling, and boxing require regular weigh-ins. Diuretics are sometimes used by athletes to lose weight quickly in order to compete in lower-weight classes. The pressure to keep their weight down may extend beyond the use of diuretics, leading to starvation diets and attempts to sweat off pounds in rubber suits or saunas. These and other unsafe practices can put athletes at risk for severe dehydration, seizures, and even death.

Diuretics in the sports world have another documented use. Called "masking," it is when diuretics are used to speed the elimination of banned performance-enhancing substances from the body. This practice increases the users' chances of passing mandatory drug tests. Athletes using steroids, for instance, might attempt to rid their bodies of trace amounts of the banned drug by taking diuretics.

Many sports organizations have added diuretics and other masking agents to their list of banned substances. For example, the National Football League Players Association (NFLPA) mentions diuretic use in its steroid policy. The organization notes that "masking agents or diuretics used to hide [the presence of steroids and other performance-enhancing substances]" are considered "Prohibited Substances." Steroids, masking agents, diuretics, and other banned substances "have no legitimate place in professional football."

Effects on the Body

There are three main classes of diuretics: loop diuretics, potassium-sparing diuretics, and thiazide diuretics. The main function of diuretics is to increase the amount of sodium and fluids excreted by the kidneys.

Kidneys and Electrolytes

The kidneys are the urine-producing organs of the body. They act as filters for body fluids, sifting out waste products and keeping important body chemicals called electrolytes at steady levels. As the Kidney Learning System Web site points out, another key function of these "powerful chemical factories" is to "remove drugs from the body."

Sodium, potassium, chloride, calcium, and magnesium are all examples of electrolytes. These chemicals are present in the body's fluids and help move nutrients into cells and wastes out of them. Nerve, muscle, and heart functions depend on proper levels of electrolytes in the body. The use of diuretics, however, can trigger electrolyte imbalances. This occurs because diuretics increase the amount of urine the body releases. Sodium, potassium, and other electrolytes can be removed from the body along with the urine.

The kidneys work to keep electrolyte concentrations in the blood at an even level. However, swings in body fluid chemicals do occur. Improper levels of electrolytes can cause a variety of symptoms, including confusion, fainting, dizziness, and headache.

Reducing Fluid Levels

In general, diuretics work by encouraging the loss of sodium and fluid from the body. This is the key to their effectiveness in treating high blood pressure and congestive heart failure.

People who suffer from long-term high blood pressure are said to have hypertension. Hypertension occurs when the force of blood against the blood vessel walls increases. This condition may be treated with diuretics from all three classes. Those used most often include thiazides such as chlorothiazide and hydrochlorothiazide; the potassium-sparing diuretic spironolactone; and the loop diuretic furosemide. Diuretics relieve hypertension by flushing excess water and sodium from the body. Lower fluid levels decrease the pressure on blood vessels and help improve blood circulation, resulting in lower blood pressure.

Congestive heart failure occurs when the pumping ability of the heart is impaired. Loop diuretics such as furosemide are most frequently prescribed to reduce the edema that results from congestive heart failure. Thiazide and potassium-sparing diuretics may also be prescribed.

Doctors also prescribe diuretics for other conditions that cause fluid retention, including certain types of diabetes and various diseases of the kidneys and the liver. Water retention related to menstruation is usually relieved with over-the-counter diuretics containing Pamabrom (Pamprin).

Among the more common side effects of diuretic use are nausea, dizziness, skin rashes, sensitivity to sunlight, high blood sugar levels, and an inability to control urination. Less common side effects associated with diuretic use include hearing loss, lowered red blood cell or white blood cell levels, and inflammation of the pancreas, a gland vital to digestion.

The All-Important Kidney

Just how important are the kidneys? The National Kidney Foundation's Kidney Learning System Web site reveals some interesting facts about the kidneys and their function.

• Humans have two kidneys, one on either side of the spinal column near the middle of the back.
• The kidneys are shaped like beans. They get their name from the "kidney bean."
• On average, each kidney weighs about 5 ounces.
• The kidneys filter about 200 quarts of fluid in a 24-hour period.
• Of those 200 quarts of fluid, about 2 quarts are made into urine and excreted from the body.
• The other 198 quarts of fluid are "cleaned up" and returned to the bloodstream.
• Urine is usually stored in the bladder anywhere from one hour to eight hours before it is excreted.
• Diabetes and high blood pressure are the most common causes of kidney disease.
• Over-the-counter pain relievers taken in large doses or for more than several weeks at a time can cause serious damage to the kidneys.

The Loop Diuretics and Their Action on the Kidneys

Each kidney consists of about 1 million nephrons held in place by supporting tissue. Nephrons are the tiny filtering units of the kidney. These structures are responsible for moving fluids and waste out of the bloodstream, resulting in urine formation. Loop diuretics take their name from the part of the kidney upon which they work—the loop of Henle. The loop of Henle is a branch within each nephron where sodium and potassium are reabsorbed back into the bloodstream instead of being filtered into the urine. Loop diuretics inhibit this action and promote excretion of the sodium and potassium instead, along with calcium, magnesium, and, of course, water. Loop diuretics are considered the most powerful of all diuretics. Bumetanide (Bumex), furosemide (Lasix), and torsemide (Demadex) are all loop diuretics.

The Potassium Balancing Act and Other Things to Know about Diuretics

Two other classes of diuretics are the thiazides and the potassium-sparing diuretics. Thiazide diuretics such as chlorothiazide and hydrochlorothiazide work by blocking sodium reabsorption by the kidneys. They are "potassium-depleting" diuretics, meaning that they cause a loss of potassium from the body. This condition is known as hypokalemia. This loss may be reversed by eating potassium-rich foods, such as bananas, or by taking potassium supplements. Signs of hypokalemia include a rapid or irregular heartbeat, fatigue, weakness, mood swings, muscle cramps, nausea, vomiting, a dry mouth, and persistent thirst.

The diuretics amiloride, spironolactone, and triamterene are known as "potassiumsparing" diuretics. This type of diuretic is used commonly in the treatment of congestive heart failure. Their use may cause hyperka lemia, a condition where there is too much potassium in the body. Signs of hyperkalemia include an irregular heartbeat, tiredness, weakness, difficulty breathing, numbness, a tingling sensation in the hands or feet, anxiety, and difficulty concentrating.

Sometimes, potassium-sparing diuretics are used in conjunction with thiazide diuretics to keep potassium levels in the user's body stable. One drug known by the brand name Dyazide is a good example of a combination-type diuretic. It contains hydrochlorothiazide (a thiazide diuretic that causes a loss of potassium in the body) and triamterene (a diuretic that helps the body retain potassium).

Other Risks:

The use of diuretics can be especially risky among pregnant women, people with compromised immune systems, and individuals with certain drug allergies. Physicians must be made aware of a patient's complete medical history before they can prescribe diuretics safely. Individuals who take diuretics for more than six months at a time run the risk of developing chemical imbalances that can result in serious side effects.

Natural Diuretics

In his book The Healing Power of Foods, nutritional expert Michael T. Murray details the natural medicinal properties of common foods. The following foods and spices are considered natural diuretics:

• watermelon
• horseradish
• pepper
• celery
• herbal salads that include ingredients such as dandelion leaves

Magnesium deficiency may occur with long-term use of the loop and thiazide diuretics. Symptoms include nausea and vomiting, muscle cramps, weakness (especially when exercising), insomnia, an irregular heartbeat, and difficulty sleeping. Calcium deficiency is a possible side effect of both loop and potassium-sparing diuretics. Signs of insufficient calcium in the body include a rapid heartbeat, muscle cramps, bone thinning, tooth decay, and difficulty sleeping.

Dehydration

Diuretic use in sports is usually prompted by the belief that a lower weight will improve athletic performance. However, the side effects experienced from long-term diuretic abuse typically offset any temporary gains in ability.

The main risk of diuretic abuse is severe dehydration. This is of special concern to athletes who might take the drug to "make weight" for sporting events or to improve performance. People exercising or participating in athletic competition are already at risk for dehydration because they are losing large amounts of fluids and electrolytes in their sweat. Diuretics can speed up this process.

Patients on doctor-prescribed diuretics must take extra precautions when exercising. These include: 1) drinking adequate amounts of water, sports drinks, or other non-caffeinated fluids; 2) wearing loose and comfortable clothing; 3) setting aside time for regular rest periods; and 4) watching for signs of heat exhaustion.

It is absolutely essential that a patient remain in regular touch with the prescribing doctor throughout the course of diuretic therapy.

Reactions with Other Drugs or Substances

Over-the-counter diuretic preparations are available in any drug store. Even though some diuretics are available without a prescription, the risk for serious side effects remains. Diuretics should always be taken under the recommendation and guidance of a trained healthcare professional.

Diuretics affect potassium levels. Drugs that are known to decrease potassium levels (certain anti-inflammatory steroids and heart drugs, for instance) should be avoided by anyone taking potassium-depleting diuretics. Potassium deficiencies can cause potentially dangerous side effects. In contrast, patients taking potassium-sparing diuretics such as amiloride, spironolactone, or triamterene should not eat foods high in potassium. The action of these diuretics raises the amount of potassium in their bodies. Thus, food rich in potassium—bananas, tomatoes, sweet potatoes, and oranges, to name a few—would only add to the problem and should be avoided.

Individuals taking prescription diuretics should always check with their doctors before adding herbal supplements

to their drug regimen. Herbal diuretics can actually increase the effect of prescription diuretics, so the two should not be combined. Some of the more well-known diuretic herbs include bilberry, celery seed, dandelion leaf, goldenrod, horse chestnut seeds, juniper, parsley, and St. John's wort. Foods and beverages rich in caffeine—such as chocolate, coffee, and tea—can also have a diuretic effect at high doses. They should not be consumed in excess with prescription diuretics. Alcohol has a diuretic effect as well and should be avoided by patients taking doctor-prescribed diuretics.

Treatment for Habitual Users

Treatment for diuretic abuse starts with examining an individual's reasons for taking the drugs. People mainly abuse diuretics in order to lose weight. These individuals include people with eating disorders as well as athletes trying to make a certain weight class.

Help for Disordered Eaters and Athletic Abusers

The National Eating Disorders Association Web site suggests that "the most effective and long-lasting treatment for an eating disorder is some form of psychotherapy or counseling, coupled with careful attention to medical and nutritional needs." Experts consider emotional support and behavioral therapy—sometimes referred to as "talk" therapy—essential for treatment and rehabilitation. It is vital to address the emotional motives and distorted thinking behind the behavior of a patient with an eating disorder.

The main goals of treatment are: 1) to stabilize the patient's weight; 2) to put an end to self-destructive behaviors, such as diuretic abuse, binge eating, and self-starvation; and 3) to help the patient relearn healthy nutritional practices. Patients with anorexia may be so severely malnourished that they require intravenous feeding in a hospital setting. Nutritional counseling and advice on lifestyle changes can help the patient reach and maintain a healthy weight.

What is an eating disorder? Some basic facts

Eating Disorders—such as anorexia, bulimia, and binge eating disorder—include extreme emotions, attitudes, and behaviors surrounding weight and food issues. Eating disorders are serious emotional and physical problems that can have life-threatening consequences for females and males.

Anorexia nervosa is characterized by self-starvation and excessive weight loss.

Symptoms include:

• Refusal to maintain body weight at or above a minimally normal weight for height, body type, age, and activity level
• Intense fear of weight gain or being "fat"
• Feeling "fat" or overweight despite dramatic weight loss
• Loss of menstrual periods
• Extreme concern with body weight and shape

Bulimia nervosa is characterized by a secretive cycle of binge eating followed by purging. Bulimia includes eating large amounts of food—more than most people would eat in one meal—in short periods of time, then getting rid of the food and calories through vomiting, laxative abuse, or over-exercising.

Symptoms include:

• Repeated episodes of bingeing and purging
• Feeling out of control during a binge and eating beyond the point of comfortable fullness
• Purging after a binge (typically by self-induced vomiting, abuse of laxatives, diet pills and/or diuretics, excessive exercise, or fasting)
• Frequent dieting
• Extreme concern with body weight and shape

Binge eating disorder (also known as compulsive overeating) is characterized primarily by periods of uncontrolled, impulsive, or continuous eating beyond the point of feeling comfortably full. While there is no purging, there may be sporadic fasts or repetitive diets and often feelings of shame or self-hatred after a binge. People who overeat compulsively may struggle with anxiety, depression, and loneliness, which can contribute to their unhealthy episodes of binge eating. Body weight may vary from normal to mild, moderate, or severe obesity.

Other eating disorders can include some combination of the signs and symptoms of anorexia, bulimia, and/or binge eating disorder. While these behaviors may not be clinically considered a full syndrome eating disorder, they can still be physically dangerous and emotionally draining. All eating disorders require professional help.

source: "What Is an Eating Disorder? Some Basic Facts," National Eating Disorders Association, Seattle, WA, 2003. www.NationalEatingDisorders.org

Athletes who abuse or misuse diuretics for purposes of performance enhancement or "making weight" face special treatment challenges. Coaches, trainers, and teammates may praise weight loss and an excessively low percentage of body fat, making it harder to change one's behavior. In addition, obsessive exercise and workout routines are often rewarded in sports and competition rather than questioned. In these cases, a treatment strategy must include educational training for the coaching and training staff as well as the athlete.

Consequences

Diuretics are not a psychoactive drug and have no direct mental effects on the user. However, abuse and misuse of this medication can lead to severe dehydration, which may bring on headaches, mental confusion, and even seizures.

Patients using diuretics for a specific medical reason under a doctor's supervision rarely experience problems. The misuse of diuretics, however, can result in serious consequences for the user. Diuretic use among people suffering from eating disorders can cause their health to worsen even further. Competitive athletes who misuse diuretics, either due to an eating disorder or for performance-enhancing purposes, usually find that their athletic performance suffers in the long run.

The Law

Diuretics are not controlled substances. Federal law does not regulate their possession and use. Some diuretic drugs are even available without a prescription. For those that do require a doctor's prescription, several rules apply to their use. The U.S. Food and Drug Administration (FDA) oversees the regulation of non-controlled drugs such as diuretics. Illegally selling or distributing prescription diuretics is against the law.

Professional athletes who test positive for diuretics in Olympic competition are suspended from participation in the games. They may also be stripped of any medals they have won. At the Summer Olympic Games in Athens, Greece, in 2004, Sanamachu Chanu of India was disqualified from competition after she tested positive for a banned diuretic. Her fourth-place finish in the weightlifting competition was tossed out.

Another incident occurred at the 2000 Olympics, when three Bulgarian weightlifters tested positive for the diuretic furosemide. The athletes involved were Izabela Dragneva, winner of the gold medal; Ivan Ivanov, winner of the silver medal; and Sevdalin Minchev, winner of the bronze medal. The International Olympic Committee took back the athletes' medals after they failed their mandatory drug tests. Alan Tsagaev, another Bulgarian weightlifter whose drug test was clean, went on to win the silver in his weight class. The coach of the Bulgarian team later took responsibility for the disqualification of his players. He claimed that he did not realize furosemide was one of the ingredients in a Bulgarian medicine named Orotsetam, which he had distributed to his team.

Diuretics appear on the World Anti-Doping Agency's "2005 Prohibited List" of drugs. Since 2000, the United States has stepped up its own investigation of performance-enhancing drugs in sports by forming the U.S. Anti-Doping Agency (USADA). The agency's main goal is "to provide clean athletes with a level playing field." According to the USADA's 2004 Testing and Results Management Numbers, the diuretic hydrochlorothiazide was one of nearly twenty "adverse findings" connected with doping violations for the year.

For More Information

Books

Murray, Michael T. The Healing Power of Foods: Nutrition Secrets for Vibrant Health and Long Life. Rocklin, CA: Prima Publishing, 1993.

Physicians' Desk Reference, 59th ed. Montvale, NJ: Thomson PDR, 2004.

Schull, Patricia Dwyer. Nursing Spectrum Drug Handbook. King of Prussia, PA: Nursing Spectrum, 2005.

Silverman, Harold M. The Pill Book, 11th ed. New York: Bantam, 2004.

Periodicals

Altman, Lawrence K. "Older Way to Treat Hypertension Found Best." New York Times (December 18, 2002): p. 1A.

Anderson, Kelli. "Losing to Win." Sports Illustrated for Women (May-June, 2001): p. 88.

"Diuretics Cut Heart Attack Risk." St. Louis Post-Dispatch (January 4, 2005): p. A5.

Krauskopf, Lewis. "Spreading the Word: Doctors Tout Value of Diuretics." The Record (March 2, 2005): p. L9.

Nagourney, Eric. "Healthier Hips, with Diuretics." New York Times (September 16, 2003): p. F6.

Nagourney, Eric. "More Bananas, Fewer Strokes?" New York Times (August 13, 2002): p. F6.

Stewart, Angela. "Water Pills Lower Risk of Stroke, Study Finds." Star-Ledger (January 4, 2005): p. 5.

Web Sites

"Coach Takes Responsibility for Failed Tests." ESPN.com, September 24, 2000. http://espn.go.com/oly/summer00/news/2000/0924/774153.html (accessed July 1, 2005).

"Eating Disorders: Facts about Eating Disorders and the Search for Solutions." National Institute of Mental Health.http://www.nimh.nih.gov/publicat/eatingdisorders.cfm (accessed July 1, 2005).

"Eating Disorders Information Index." National Eating Disorders Association.http://www.nationaleatingdisorders.org (accessed July 1, 2005).

Freudenrich, Craig C. "How Your Kidneys Work." How Stuff Works.http://science.howstuffworks.com/kidney.htm/printable (accessed July 1, 2005).

"How Your Kidneys Work." Kidney Learning System.http://www.kidney.org/kls/public/howkidneyswrk.cfm (accessed July 1, 2005).

"Lasker Awards: Former Awards." Lasker Foundation.http://www.laskerfoundation.org/awards/other.html (accessed July 1, 2005).

"News Release: The Changing Face of Eating Disorders." National Eating Disorders Association.http://www.nationaleatingdisorders.org/p.asp?WebPage_ID=805 (accessed July 1, 2005).

"Steroid Policy—Full." National Football League Players Association. http://www.nflpa.org/agents/main.asp?subpage=Steroid+Policy+?+Full&section=ALL (accessed July 5, 2005).

"United States Anti-Doping Agency's 2004 Annual Report." United States Anti-Doping Agency.http://www.usantidoping.org/files/active/resources/press_releases/2004%20USADA%20Annual%20Report.pdf (accessed July 1, 2005).

"What Are Electrolytes?" How Stuff Works.http://science.howstuffworks.com/question565.htm (accessed July 1, 2005).

"William Withering." BBC Historical Figures. http://www.bbc.co.uk/history/historic_figures/withering_william.shtml (accessed July 1, 2005).

"The World Anti-Doping Code: The 2005 Prohibited List." World Anti-Doping Agency.http://www.wada-ama.org/rtecontent/document/list_2005.pdf (accessed July 1, 2005).

See also: Caffeine; Creatine; Diet Pills; Herbal Drugs; Over-the-Counter Drugs