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# Aldactone (spironolactone) ## Overview Spironolactone is a potassium-sparing diuretic and a competitive aldosterone antagonist. ## Primary Indications 1. **Heart Failure:** To reduce mortality and hospitalizations in patients with symptomatic chronic heart failure (NYHA class II-IV) and reduced ejection fraction. 2. **Hypertension:** As add-on therapy for patients with resistant hypertension. 3. **Edema:** Associated with congestive heart failure, cirrhosis, and nephrotic syndrome. 4. **Primary Hyperaldosteronism:** For diagnosis or treatment. ## Adult Dosing * **Heart Failure:** Initiate at 25 mg once daily. May titrate to 50 mg once daily within 1 week. Further titration to a maximum of 100 mg once daily may be considered based on clinical response and potassium levels. * **Hypertension:** Initiate at 25-100 mg once daily. May be increased to achieve target blood pressure. Max dose: 400 mg daily. Often used in combination with other antihypertensives. * **Edema (Cirrhosis/Nephrotic Syndrome):** Initiate at 25-100 mg once daily. Dose may be adjusted based on response. Max dose: 400 mg daily. * **Primary Hyperaldosteronism:** Preoperative treatment: 100-400 mg daily. Long-term management: 25-400 mg daily. ## Pediatric Dosing * **Hypertension:** 1.5-3 mg/kg/day in 1-4 divided doses. Max: 100 mg/day. * **Edema/Congestive Heart Failure:** 1-3 mg/kg/day in 1-4 divided doses. Max: 100 mg/day. * **Pediatric dosing is less well-established and may depend on local protocols or expert consultation.** ## Dose Adjustments * **Renal Impairment:** Use with caution in patients with impaired renal function. Avoid in severe renal impairment. * **Hepatic Impairment:** Use with caution in patients with hepatic impairment, as it can precipitate hepatic coma. ## Contraindications * Anuria * Acute renal insufficiency * Significant impairment of renal excretory function * Hyperkalemia * Addison's disease * Concomitant use with eplerenone ## Adverse Effects * **Endocrine:** Gynecomastia, menstrual irregularities, breast tenderness, impotence, decreased libido, deepening of the voice. * **Electrolyte:** Hyperkalemia, hyponatremia, dehydration. * **Gastrointestinal:** Nausea, vomiting, diarrhea, gastric bleeding, abdominal cramps. * **Hepatic:** Hepatotoxicity, hepatic coma. * **Renal:** Renal dysfunction, interstitial nephritis. * **Dermatologic:** Rash, pruritus, urticaria. ## Key Drug Interactions * **ACE inhibitors, ARBs, NSAIDs, potassium supplements, and eplerenone:** Increased risk of hyperkalemia. * **Digoxin:** Spironolactone may increase digoxin levels. * **Non-steroidal anti-inflammatory drugs (NSAIDs):** Can reduce the diuretic and antihypertensive effects of spironolactone and exacerbate renal impairment and hyperkalemia. * **Corticosteroids:** May cause sodium retention and reduce response to spironolactone. * **Bupivacaine:** May prolong neuromuscular blockade. ## Monitoring * Serum electrolytes (especially potassium) and renal function (BUN, creatinine) at baseline and periodically thereafter, especially in patients with renal impairment or those receiving other potassium-sparing agents. * Blood pressure. * Signs and symptoms of hyperkalemia (weakness, fatigue, ECG changes). * Signs and symptoms of fluid overload or dehydration. * In heart failure patients, monitor for worsening symptoms or signs of hyperkalemia. ## Clinical Pearls * Spironolactone's anti-androgenic effects may be responsible for some of its adverse effects (e.g., gynecomastia). * Due to its long half-life, spironolactone can be dosed once daily. * Onset of diuretic effect is typically within 24 hours, with maximum effect in 48-72 hours. * In heart failure, initiation and titration require careful monitoring of potassium and renal function. *** **Educational Disclaimer:** This information is for educational purposes only and does not substitute for professional medical advice. Always consult with a qualified healthcare provider to ensure that the information provided is accurate, complete, and appropriate for your specific situation. Prescribing information can change, and it is crucial to refer to the most current official drug labeling for definitive guidance.