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# Aldactone (spironolactone)
## Overview
Spironolactone is a potassium-sparing diuretic and an aldosterone antagonist.
## Primary Indications
* Heart failure (NYHA class II-IV)
* Hypertension
* Edema associated with cirrhosis or nephrotic syndrome
* Primary hyperaldosteronism
## Adult Dosing
* **Heart Failure:** Start at 25 mg once daily. May increase to 50 mg once daily. If not tolerated, may adjust to 25 mg every other day. Maximum dose: 100 mg daily.
* **Hypertension:** Start at 25-100 mg once daily, divided into 1-2 doses. Maximum dose: 200 mg daily.
* **Edema (Cirrhosis/Nephrotic Syndrome):** Start at 25-100 mg once daily, divided into 1-2 doses. Maximum dose: 200 mg daily.
* **Primary Hyperaldosteronism:** Preoperative: 100-400 mg daily, divided into 2-4 doses. Postoperative: may be continued at a lower dose to manage hypertension or electrolyte imbalance.
## Pediatric Dosing
* **Heart Failure & Edema:** 1.5 to 3 mg/kg/day divided into 2-4 doses. Maximum dose: 100 mg/day.
* **Hypertension:** 1.5 to 3 mg/kg/day divided into 2-4 doses. May increase dose based on response and tolerance. Maximum dose: 3 mg/kg/day or 100 mg/day (whichever is less).
* *Note: Pediatric dosing is highly variable and should be guided by expert clinical judgment and local protocols.*
## Dose Adjustments
* **Renal Impairment:** Use with caution. Monitor electrolytes closely. Generally avoid if eGFR is <30 mL/min/1.73m².
* **Hepatic Impairment:** Use with caution due to increased risk of hyperkalemia and hepatic encephalopathy, especially in patients with severe cirrhosis.
## Contraindications
* Anuria
* Significant renal impairment
* Hyperkalemia
* Addison's disease
* Concomitant use with eplerenone
## Adverse Effects
* **Common:** Hyperkalemia, hyponatremia, gynecomastia, menstrual irregularities, erectile dysfunction, fatigue, dizziness, headache, gastrointestinal upset.
* **Less Common:** Nausea, vomiting, diarrhea, rash, fever, confusion, muscle cramps.
* **Serious:** Severe hyperkalemia (potentially life-threatening), Stevens-Johnson syndrome, toxic epidermal necrolysis, hypersensitivity reactions.
## Key Drug Interactions
* **ACE inhibitors, ARBs, NSAIDs, Potassium supplements, Heparin, Trimethoprim/sulfamethoxazole:** Increased risk of hyperkalemia.
* **Corticosteroids:** May increase risk of hyponatremia.
* **Digoxin:** Spironolactone may increase digoxin levels, increasing the risk of toxicity.
* **Lithium:** Spironolactone can decrease lithium clearance, leading to lithium toxicity.
* **Non-steroidal anti-inflammatory drugs (NSAIDs):** May reduce the diuretic and antihypertensive effects of spironolactone.
## Monitoring
* Serum potassium levels (frequently, especially at initiation, dose changes, or in patients with renal impairment).
* Renal function (serum creatinine or eGFR).
* Electrolytes (sodium).
* Blood pressure.
* Signs and symptoms of hyperkalemia (e.g., palpitations, muscle weakness, paresthesias).
* Signs and symptoms of gynecomastia or menstrual irregularities.
## Clinical Pearls
* Administer with food to improve absorption and reduce gastrointestinal upset.
* Spironolactone's effect on potassium levels is dose-dependent and unpredictable; regular monitoring is crucial.
* Consider spironolactone's anti-androgenic effects, which can contribute to gynecomastia and menstrual irregularities.
* In heart failure, spironolactone is indicated to reduce mortality and hospitalizations.
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*Please verify current prescribing information with the most recent FDA-approved labeling or a trusted drug information resource.*
