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# Aldactone (spironolactone)
## Overview
Aldactone is a potassium-sparing diuretic and aldosterone antagonist. It blocks the mineralocorticoid receptor in the distal nephron, reducing sodium reabsorption and potassium excretion. Used primarily for heart failure, hypertension, and edema.
## Primary Indications
- Heart failure with reduced ejection fraction (HFrEF)
- Hypertension (as add-on therapy)
- Edema in cirrhosis, nephrotic syndrome, or primary hyperaldosteronism
- Acne vulgaris and hirsutism (off-label)
## Adult Dosing
- **Heart failure (HFrEF)**: Start 12.5–25 mg once daily; titrate to 25 mg daily (max 50 mg daily).
- **Hypertension**: 25–100 mg daily in 1–2 divided doses; max 100 mg/day.
- **Edema/cirrhosis**: 100 mg daily initially; adjust to 25–200 mg/day.
- **Primary hyperaldosteronism**: 100–400 mg daily in divided doses.
- Note: Use lowest effective dose; local protocols may vary.
## Pediatric Dosing
- **Diuretic/edema**: 1–3 mg/kg/day divided every 6–24 hours; max 3–4 mg/kg/day (200 mg/day).
- **Hypertension**: 1–2 mg/kg/day divided once or twice; max 3 mg/kg/day (100 mg/day).
- Dosing not well-established in neonates; adjust based on response and electrolytes.
## Dose Adjustments
- **Renal impairment**: Avoid if eGFR <30 mL/min; use with caution if >30 mL/min.
- **Hepatic impairment**: No specific adjustment, but monitor electrolytes closely in cirrhosis.
- **Elderly**: Start at lower end of dosing range (e.g., 12.5–25 mg daily).
## Contraindications
- Hyperkalemia (serum K+ >5.5 mEq/L)
- Severe renal impairment (eGFR <30 mL/min) or anuria
- Addison’s disease
- Concomitant use with eplerenone or other potassium-sparing diuretics
- Hypersensitivity to spironolactone
## Adverse Effects
- **Hyperkalemia** (most serious; risk increases with renal impairment, diabetes, or other drugs)
- Gynecomastia, breast tenderness (dose-related, reversible)
- Menstrual irregularities, impotence in men
- GI upset, drowsiness, ataxia
- Rare: agranulocytosis, hepatotoxicity, Stevens-Johnson syndrome
## Key Drug Interactions
- **ACE inhibitors, ARBs, aliskiren**: Increased risk of hyperkalemia.
- **Potassium supplements or salt substitutes**: Avoid.
- **NSAIDs**: Reduced diuretic effect and increased hyperkalemia risk.
- **Digoxin**: Spironolactone may increase digoxin levels (monitor).
- **Lithium**: Increased lithium toxicity risk.
- **Warfarin**: Spironolactone may decrease anticoagulant effect (monitor INR).
## Monitoring
- Serum potassium and creatinine at baseline, within 1 week of initiation, and periodically thereafter (especially with dose changes or interacting drugs).
- Blood pressure, weight, signs/symptoms of hyperkalemia (weakness, paresthesias, arrhythmias).
- Monitor for gynecomastia in long-term use.
## Clinical Pearls
- Take with food to reduce GI upset.
- Dosing should be once daily when possible to improve adherence.
- Do not crush extended-release formulations (if applicable; most spironolactone is immediate-release).
- Can be combined with thiazide diuretics to counter hypokalemia and maintain potassium balance.
- Half-life is ~1.4 hours but active metabolites prolong effect; steady state in ~3 days.
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**Disclaimer:** This information is for educational purposes and does not replace current prescribing guidelines. Always verify dosing, indications, and safety information with the most recent manufacturer labeling, local protocols, and clinical judgment.
