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# Aldactone (spironolactone)
## Overview
Spironolactone is a potassium-sparing diuretic and an aldosterone antagonist.
## Primary Indications
* **Heart Failure:** To reduce mortality in patients with symptomatic heart failure with reduced ejection fraction (NYHA class II-IV).
* **Edema/Ascites:** In patients with edema due to heart failure, cirrhosis, or nephrotic syndrome.
* **Hypertension:** As add-on therapy for patients not adequately controlled on other agents.
* **Primary Hyperaldosteronism:** For diagnosis or treatment.
* **Hirsutism in Women:** Off-label use for androgenetic effects.
## Adult Dosing
* **Heart Failure:** Start at 25 mg once daily. May titrate to 25 mg twice daily or 50 mg once daily based on tolerance and response. Maximum recommended dose is 50 mg twice daily.
* **Edema/Ascites (Cirrhosis):** Start at 25-100 mg once daily. May adjust dose based on response and tolerance. Maximum usually 400 mg daily.
* **Edema (Non-cirrhotic):** Start at 100 mg once daily. May adjust dose. Maximum usually 200 mg daily.
* **Hypertension:** Start at 25-100 mg once daily. May adjust dose. Maximum usually 200 mg daily.
* **Primary Hyperaldosteronism:** Preoperative: 100-400 mg daily. Long-term: 25-100 mg daily for maintenance.
* **Hirsutism:** 50-200 mg once daily.
Dosing for specific indications can vary. Consult local protocols.
## Pediatric Dosing
Dosing in pediatric patients is highly variable and should be guided by specialist recommendations and clinical response. General guidelines suggest:
* **Hypertension:** 1-3 mg/kg/day divided into 1-2 doses. Maximum 3 mg/kg/day or 100 mg/day total.
* **Edema:** 1-3 mg/kg/day divided into 1-2 doses. Maximum 3 mg/kg/day or 200 mg/day total.
## Dose Adjustments
* **Renal Impairment:** Use with caution. Monitor serum potassium and creatinine closely. Generally avoided in severe renal impairment.
* **Hepatic Impairment:** Use with caution due to increased risk of hyperkalemia and hepatic encephalopathy.
## Contraindications
* Anuria
* Acute renal insufficiency
* Significant or progressive renal impairment
* Hyperkalemia
* Addison's disease
* Concomitant use of eplerenone
## Adverse Effects
* **Endocrine:** Gynecomastia, menstrual irregularities, breast tenderness, impotence, decreased libido.
* **Electrolyte Imbalances:** Hyperkalemia (most serious), hyponatremia, hyperchloremic metabolic acidosis.
* **Gastrointestinal:** Nausea, vomiting, diarrhea, abdominal cramps.
* **Renal:** Increased BUN and creatinine.
* **Other:** Drowsiness, confusion, rash, alopecia.
## Key Drug Interactions
* **ACE Inhibitors, ARBs, NSAIDs, Potassium Supplements, Heparin, Trimethoprim:** Increased risk of hyperkalemia.
* **Potassium-Sparing Diuretics (e.g., Amiloride, Triamterene):** Additive hyperkalemic effects.
* **Corticosteroids:** May increase potassium loss.
* **Digoxin:** Spironolactone may increase digoxin levels.
* **Lithium:** Spironolactone may decrease lithium clearance, increasing lithium toxicity risk.
## Monitoring
* **Serum Potassium:** Monitor frequently, especially at initiation, dose changes, and in those with renal impairment or taking other drugs that increase potassium.
* **Renal Function (BUN, Creatinine):** Monitor at baseline and periodically.
* **Electrolytes (Sodium):** Monitor periodically.
* **Blood Pressure:** Monitor for efficacy and hypotension, especially in hypertension and heart failure.
* **Symptoms of Gynecomastia/Breast Tenderness:** Assess regularly.
## Clinical Pearls
* Administer with food to enhance absorption.
* Dosing is often once daily, but twice daily dosing may improve efficacy for some indications.
* Risk of hyperkalemia is significant, especially with impaired renal function or concomitant use of other drugs affecting potassium levels. Educate patients on diet and symptoms of hyperkalemia.
* Hirsutism response may take several months.
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*This information is intended as a clinical reference and does not substitute for professional medical advice. Always verify current prescribing information and consult with a qualified healthcare provider for specific patient care decisions.*
