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# Aldactone (spironolactone)
## Overview
Spironolactone is a potassium-sparing diuretic that acts as an aldosterone antagonist.
## Primary Indications
* **Heart Failure:** To reduce mortality and hospitalizations in patients with symptomatic heart failure (NYHA class II-IV) with reduced ejection fraction, usually in addition to standard therapy.
* **Edema/Ascites:** Management of edema and ascites in patients with hepatic cirrhosis or congestive heart failure.
* **Hypertension:** Adjunctive therapy in patients whose blood pressure is not adequately controlled with other antihypertensives.
* **Primary Hyperaldosteronism:** Diagnosis and management.
* **Hirsutism/Acne (Off-label):** Management of moderate to severe hirsutism or acne in women, particularly when androgen levels are elevated.
## Adult Dosing
* **Heart Failure:** Start at 25 mg once daily. May increase to 50 mg once daily after 4 weeks. If not tolerated, may reduce dose. If still indicated and tolerated, may increase to 50 mg twice daily if needed. Target dose typically 25-50 mg once or twice daily.
* **Edema/Ascites (Cirrhosis):** Start at 100 mg once daily. May adjust dose between 25 mg and 400 mg daily depending on response.
* **Edema (Congestive Heart Failure):** Start at 100 mg once daily. May adjust dose between 25 mg and 400 mg daily depending on response.
* **Hypertension:** Start at 25-100 mg once daily. May be combined with other antihypertensives. Doses up to 200 mg daily may be used.
* **Primary Hyperaldosteronism:** Preoperative: 100-400 mg daily. Postoperative/long-term management: 25-100 mg daily.
* **Hirsutism/Acne:** 25-200 mg once daily. Often initiated at 25-50 mg once daily and titrated up.
## Pediatric Dosing
Dosing in children is highly variable and often requires specialist consultation. General guidelines include:
* **Diuretic/Antihypertensive:** 1-3 mg/kg/day divided into 1-2 doses. Maximum dose generally 100 mg/day (up to 200 mg/day in rare cases).
* **Edema/Ascites:** Similar to diuretic dosing.
* **Hirsutism:** Lower doses may be used, starting at 0.5-1 mg/kg/day.
## Dose Adjustments
* **Renal Impairment:** Use with caution in patients with renal impairment. Monitor potassium closely. Specific dose adjustments depend on creatinine clearance and potassium levels.
## Contraindications
* Anuria
* Acute renal insufficiency
* Significant impairment of renal excretory function
* Hyperkalemia
* Addison's disease
* Concomitant use with eplerenone
## Adverse Effects
* **Common:** Hyperkalemia, hyponatremia, gynecomastia, breast pain, menstrual irregularities, fatigue, dizziness, gastrointestinal upset (nausea, vomiting, diarrhea).
* **Serious:** Severe hyperkalemia, Stevens-Johnson syndrome, toxic epidermal necrolysis, interstitial nephritis, feminization.
## Key Drug Interactions
* **ACE Inhibitors/ARBs/DRIs/Potassium Supplements/Salt Substitutes/Heparin:** Increased risk of hyperkalemia.
* **NSAIDs:** May reduce diuretic and antihypertensive effect; increased risk of hyperkalemia.
* **Digoxin:** Spironolactone can increase digoxin levels, increasing the risk of toxicity.
* **Lithium:** Spironolactone can reduce renal clearance of lithium, increasing the risk of lithium toxicity.
* **Choline Magnesium Trisalicylate:** May increase serum potassium levels.
## Monitoring
* **Electrolytes:** Monitor serum potassium and sodium frequently, especially when initiating therapy, increasing dose, or in patients with renal impairment.
* **Renal Function:** Monitor serum creatinine and BUN.
* **Blood Pressure:** Monitor for hypotension.
* **For Hirsutism/Acne:** Monitor for efficacy and adverse effects.
## Clinical Pearls
* Administer with food to improve absorption and reduce gastrointestinal upset.
* Dose is often adjusted based on clinical response and electrolyte levels.
* Gastrointestinal side effects are common.
* Gynecomastia and menstrual irregularities are dose-related and reversible upon discontinuation.
* Hyperkalemia is the most serious adverse effect; caution is advised in patients with renal impairment or those taking other medications that increase potassium.
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Please verify current prescribing information for the most up-to-date details.
