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# Aldactone (spironolactone)
## Overview
Potassium-sparing diuretic and aldosterone antagonist. Used for its antihypertensive, diuretic, and antiandrogen properties.
## Primary Indications
- Heart failure with reduced ejection fraction (HFrEF)
- Resistant hypertension
- Cirrhosis with ascites & edema
- Primary hyperaldosteronism (diagnosis and management)
- Off-label: acne vulgaris, hirsutism (due to antiandrogen activity)
## Adult Dosing
- **Heart failure**: Initiate 12.5–25 mg once daily; titrate to 25–50 mg once daily. Max 50 mg/day.
- **Hypertension (resistant)**: 25–100 mg/day in 1–2 divided doses. Max 100 mg/day.
- **Cirrhosis with ascites**: 100–400 mg/day in 1–2 divided doses (usually start 100 mg/day).
- **Primary hyperaldosteronism**: 100–400 mg/day for maintenance.
## Pediatric Dosing
- **Diuretic (edema/ascites)**: 1–3 mg/kg/day in divided doses (every 6–24 hours). Max 3–4 mg/kg/day (up to 100–200 mg/day depending on size).
- **Hypertension**: 1–2 mg/kg/day in 1–2 doses; titrate as needed. Max 3 mg/kg/day (up to 100 mg/day).
Exact dosing depends on local protocol and indication.
## Dose Adjustments
- **Renal impairment**: Avoid if CrCl <10 mL/min; use with caution and monitor K+ if CrCl 10–30 mL/min; no dose adjustment for mild impairment.
- **Hyperkalemia risk**: Reduce dose or discontinue if K+ >5.0–5.5 mEq/L (per local protocol).
- **Elderly**: Start at lower end of dosing range.
## Contraindications
- Anuria, acute renal insufficiency, severe renal impairment (CrCl <10 mL/min)
- Hyperkalemia (serum K+ >5.5 mEq/L)
- Addison's disease
- Concomitant use of eplerenone or other potassium-sparing diuretics
- Known hypersensitivity
## Adverse Effects
- **Common**: Hyperkalemia, gynecomastia (dose-related, reversible), menstrual irregularities, GI upset, dizziness.
- **Serious**: Severe hyperkalemia (arrhythmias), acute renal failure, hypotension, metabolic acidosis.
- **Others**: Decreased libido, impotence, drowsiness, rash.
## Key Drug Interactions
- **Hyperkalemia potentiators**: ACE inhibitors, ARBs, direct renin inhibitors, potassium supplements, NSAIDs, heparin.
- **Digoxin**: Spironolactone may increase digoxin levels (monitor).
- **Lithium**: Increased risk of lithium toxicity.
- **Other antihypertensives**: Additive hypotensive effect.
- **NSAIDs**: Reduced diuretic effect and increased risk of renal impairment.
## Monitoring
- Baseline and periodic: serum potassium (especially after initiation, dose changes, or with renal impairment), BUN, creatinine, blood pressure.
- In heart failure: monitor for signs of hyperkalemia (ECG if K+ >6.0 mEq/L).
- For antiandrogen use: monitor menstrual pattern, gynecomastia.
## Clinical Pearls
- Gynecomastia occurs in ~10% of men at 100 mg/day; lower doses reduce risk.
- For resistant hypertension, effective add-on to an ACE/ARB + thiazide (but monitor K+ closely).
- Antiandrogen effects make it useful off-label for female acne/hirsutism (25–100 mg/day, with contraception due to antiandrogen impact on fetus).
- Onset of diuretic effect is gradual (2–3 days); full antihypertensive effect may take 2 weeks.
- Avoid potassium-rich foods/supplements during therapy.
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*Educational disclaimer: This information is for educational purposes and not a substitute for professional medical judgment. Always consult local guidelines, product information, and verify dosing with clinical context.*
