Spironolactone

Aka: Spironolactone, Aldactone

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II. Indications

  1. Left-sided Congestive Heart Failure
    1. First line agent for NYHA Class III or IV Heart Failure, in conjunction with ACE Inhibitor and Beta Blocker
    2. Monitor for Hyperkalemia (esp. with ACE Inhibitor) and renal dysfunction
    3. May use Eplerenone as an alternative (but more expensive)
  2. Edematous States
    1. Cirrhosis
    2. Primary Hyperaldosteronism
    3. Nephrotic Syndrome
  3. Hyperandrogenism in women
    1. Hirsutism
    2. Polycystic Ovary Disease
  4. Hyperaldosteronism
    1. First-line treatment for Hyperaldosteronism
  5. Refractory Hypertension
    1. See Hypertension Combination Therapy

III. Contraindications

  1. Anuria
  2. Renal Insufficiency with Serum Creatinine over 2.4 mg/dl (GFR <30 ml/minute/1.73m2)
  3. Hyperkalemia (Serum Potassium >5 meq/L)

IV. Mechanism

  1. Potassium-Sparing Diuretic via Aldosterone blockade
    1. Spironolactone is a Aldosterone competitive inhibitor
    2. Acts at distal convoluted renal tubule
    3. Inhibits Sodium retention
  2. Congestive Heart Failure
    1. Works synergistically with ACE Inhibitors in CHF
    2. ACE Inhibitors block Angiotensin II production
      1. Renal response is to increase Aldosterone
      2. Spironolactone blocks Aldosterone escape

V. Drug Interactions

  1. P-Glycoprotein Inhibitor
  2. Increased Serum Potassium (Hyperkalemia risk)
    1. Potassium Supplementation
    2. NSAIDs
    3. ACE Inhibitor
    4. Trimethoprim-Sulfamethoxazole
  3. Salicylates
    1. Decrease Spironolactone effect
  4. Digoxin
    1. Increased Digoxin Toxicity risk via increased Digoxin half life
  5. Norepinephrine
    1. Decreases NorepinephrineVasopressor activity

VI. Dosing

  1. Congestive Heart Failure
    1. Start 12.5 mg orally daily
    2. May increase to 25 mg orally daily after 4 weeks (up to 50 mg, but increased risk of Hyperkalemia)
    3. Monitor Serum Potassium at 3 days, 7 days and then monthly for the first 3 months
  2. Edema
    1. Dose: 50 to 100 mg orally per day divided once to twice daily
    2. Maximum: 200 mg/day
  3. Hyperandrogenism
    1. Dose: 50 mg orally twice daily
  4. Hypertension
    1. Dose: 12.5 to 50 mg orally daily
    2. Maximum: 100 mg
  5. Primary Hyperaldosteronism
    1. Dose: 100 to 400 mg/day preoperatively
    2. Use the lowest effective dose

VII. Monitoring

  1. Serum Potassium
  2. Renal Function (Serum Creatinine)

VIII. Pharmacokinetics

  1. Liver metabolism to active metabolite (canrenone)
  2. Primarily renal excretion
  3. Half-Life: 14 to 16 hours (up to 24-36 hours)
  4. Duration: 2 to 3 days

IX. Adverse Effects

  1. See Potassium-Sparing Diuretic
  2. Gynecomastia (in men)
  3. Mastodynia
  4. Erectile Dysfunction
  5. Alopecia
  6. Hyperkalemia
    1. Avoid excessive Dietary Potassium

X. Safety

  1. Pregnancy Category C
  2. Safe in Lactation

XI. Resources

  1. Spironolactone (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=fb66327e-8261-46ae-b39a-4fa79d520844

XII. References

  1. (2017) Presc Lett 24(12): 69
  2. Margo (2001) Am Fam Physician 64(8):1393-8 [PubMed]
  3. Pitt (1999) N Engl J Med 341:709-17 [PubMed]

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Cost: Medications

spironolactone (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
SPIRONOLACTONE 100 MG TABLET Generic $0.18 each
SPIRONOLACTONE 25 MG TABLET Generic $0.05 each
SPIRONOLACTONE 50 MG TABLET Generic $0.10 each
SPIRONOLACTONE-HYDROCHLOROTHIAZIDE 25-25 TAB Generic $0.58 each
FPNotebook does not benefit financially from showing this medication data or their pharmacy links. This information is provided only to help medical providers and their patients see relative costs. Insurance plans negotiate lower medication prices with suppliers. Prices shown here are out of pocket, non-negotiated rates. See Needy Meds for financial assistance information. GoodRx is another tool for finding lower drug prices.

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