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# Aldactone (spironolactone)
## Overview
Aldactone is a potassium-sparing diuretic and aldosterone antagonist.
## Primary Indications
* Heart failure (NYHA class II-IV)
* Hypertension (often as add-on therapy)
* Edema due to hepatic cirrhosis or nephrotic syndrome
* Primary hyperaldosteronism
## Adult Dosing
* **Heart Failure:** Initiate at 25 mg once daily. May increase to 50 mg once daily after 4 weeks if symptomatic and tolerated. Further titration to a maximum of 100 mg once daily can be considered if needed.
* **Hypertension:** Initiate at 25-100 mg/day, divided into 1-2 doses. The maximum dose is typically 400 mg/day.
* **Cirrhosis with Edema/Ascites:** Initiate at 25-100 mg/day, divided into 1-2 doses. The maximum dose is typically 400 mg/day.
* **Primary Hyperaldosteronism:** Doses vary greatly, typically ranging from 100-400 mg/day, divided into 1-2 doses.
## Pediatric Dosing
Dosing varies significantly by indication and patient weight. Consult specific pediatric guidelines or a pediatric specialist for appropriate dosing. Generally, doses range from 0.5-3 mg/kg/day divided into 1-4 doses.
## Dose Adjustments
* **Renal Impairment:** Use with caution. Contraindicated in severe renal impairment. Dose reduction may be necessary.
* **Hepatic Impairment:** Use with caution. Dose reduction may be necessary.
## Contraindications
* Anuria
* Significant renal impairment (e.g., serum creatinine > 1.5 mg/dL or CrCl < 50 mL/min)
* Hyperkalemia
* Addison's disease
* Known hypersensitivity to spironolactone
## Adverse Effects
* Hyperkalemia (most serious)
* Gynecomastia and breast tenderness (especially with higher doses)
* Menstrual irregularities
* Nausea, vomiting, diarrhea
* Dizziness, headache
* Lethargy
* Erectile dysfunction
## Key Drug Interactions
* **ACE inhibitors, ARBs, NSAIDs, potassium supplements, salt substitutes containing potassium:** Increased risk of hyperkalemia.
* **Diuretics (other than potassium-sparing):** Increased risk of dehydration and hypotension.
* **Digoxin:** Spironolactone may increase digoxin levels.
* **Lithium:** Spironolactone may decrease lithium clearance.
* **Cholestyramine:** Increased risk of hyperkalemia.
## Monitoring
* Serum electrolytes (especially potassium)
* Renal function (serum creatinine, BUN)
* Blood pressure
* Signs and symptoms of fluid overload or dehydration
## Clinical Pearls
* Aldactone is often used in combination with other diuretics for additive effects or to counteract potassium loss.
* Monitor potassium closely, especially when initiating therapy, increasing doses, or in patients with renal impairment or those taking other medications that increase potassium.
* Educate patients about the risk of hyperkalemia and signs/symptoms to report.
* Gynecomastia may be irreversible in some cases.
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This information is intended for healthcare professionals. Always verify current prescribing information and consult with appropriate resources before making clinical decisions.
