From the FDA Drug Label
Spironolactone is substantially excreted by the kidney, and the risk of adverse reactions to this drug may be greater in patients with impaired renal function. Patients with renal impairment are at increased risk of hyperkalemia. Monitor potassium closely.
The impact of age, sex, race/ethnicity, and renal impairment on the pharmacokinetics of spironolactone have not been specifically studied.
The patient is on dialysis, which indicates severe renal impairment. Restarting spironolactone in this patient may increase the risk of hyperkalemia due to reduced renal excretion of the drug and its metabolites.
- Key consideration: The risk of adverse reactions, particularly hyperkalemia, is greater in patients with impaired renal function.
- Recommendation: Monitor potassium levels closely if spironolactone is restarted in a patient on dialysis. 1 1
From the Research
Spironolactone can be used cautiously in patients on dialysis, but requires close monitoring, as evidenced by a study published in 2009 2, which demonstrated improved cardiac function in hemodialysis patients with moderate to severe heart failure.
Key Considerations
- The typical starting dose should be reduced to 12.5-25 mg daily with careful titration based on clinical response.
- Since spironolactone is not significantly removed by dialysis, drug accumulation can occur, potentially leading to hyperkalemia and other adverse effects.
- Regular monitoring of potassium levels, particularly before dialysis sessions, is essential.
- The medication should be temporarily held if potassium exceeds 5.5 mEq/L.
Benefits and Risks
- Spironolactone may still provide benefits for dialysis patients with resistant hypertension, heart failure, or hyperaldosteronism, but the risk-benefit ratio must be carefully assessed.
- The drug works by blocking aldosterone receptors, which can help manage fluid retention and blood pressure even in end-stage renal disease, though its potassium-sparing effects require vigilance in this population.
Monitoring and Precautions
- Serum potassium levels and renal function should be assessed prior to initiating spironolactone therapy, and periodic monitoring is recommended, especially in patients at high risk of developing hyperkalemia, as noted in a study published in 2012 3.
- Patients should be closely monitored for signs of hyperkalemia, and the medication should be adjusted or discontinued as needed to minimize the risk of adverse effects.