Can I continue Spironolactone and Furosemide (Lasix) in a patient with impaired liver function, impaired renal function, and prerenal azotemia?

From the Guidelines

Caution is advised when using spironolactone and furosemide in patients with impaired liver function, impaired renal function, and prerenal azotemia, and these medications should generally be temporarily discontinued or used at reduced doses with very close monitoring. For spironolactone, liver impairment can lead to reduced metabolism and increased risk of hyperkalemia, while renal impairment reduces its effectiveness and increases toxicity risk 1. Furosemide may worsen prerenal azotemia by reducing intravascular volume further, potentially accelerating renal deterioration. If these medications are deemed necessary, start with reduced doses (25-50% of normal), monitor renal function, electrolytes (especially potassium, sodium), and fluid status daily, and adjust therapy based on clinical response 1. The underlying causes of prerenal azotemia should be addressed first, including optimizing hydration status and treating any precipitating factors. A nephrology consultation is recommended to guide management in this complex clinical scenario, as the risks of continuing these diuretics often outweigh the benefits until the patient's prerenal state is corrected.

Some key points to consider when managing patients with ascites and impaired renal function include:

• Monitoring for diuretic adverse events, such as electrolyte imbalance, worsening hypokalemia, hyperkalemia, serum creatinine, hepatic encephalopathy, and muscle cramps 1
• Temporarily discontinuing diuretics if adverse events occur, and reassessing salt intake and performing spot urine sodium/potassium ratio if suboptimal diuretic response is observed 1
• Reducing diuretic dose to the lowest possible level if ascites resolves 1
• Considering alternative treatments, such as midodrine, in refractory ascites on a case-by-case basis 1

It is essential to prioritize the patient's morbidity, mortality, and quality of life when making decisions about continuing or discontinuing spironolactone and furosemide in this complex clinical scenario. The most recent and highest-quality study, 1, provides guidance on the management of ascites in cirrhosis, including the use of diuretics, and should be consulted when making treatment decisions.

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. Because elderly patients are more likely to have decreased renal function, monitor renal function. Patients with renal impairment are at increased risk of hyperkalemia. Monitor potassium closely. Spironolactone can cause sudden alterations of fluid and electrolyte balance which may precipitate impaired neurological function, worsening hepatic encephalopathy and coma in patients with hepatic disease with cirrhosis and ascites.

Continuation of Spironolactone and Furosemide is not recommended due to the patient's impaired renal function (BUN of 33 and prerenal azotemia) and impaired liver function (SGPT of 275). The risk of adverse reactions, including hyperkalemia and worsening renal function, is increased in patients with impaired renal function. Additionally, Spironolactone can cause sudden alterations of fluid and electrolyte balance, which may precipitate impaired neurological function in patients with hepatic disease.

• Monitor renal function and potassium levels closely
• Consider alternative treatments that are safer for patients with impaired renal and liver function 2, 2, 2.

From the Research

Patient Condition

The patient has impaired liver function (SGPT 275), impaired renal function (EGFR 54), and prerenal azotemia (BUN 33).

Medication Considerations

• Spironolactone and Furosemide (Lasix) are currently being used.
• The patient's condition and medication usage raise concerns about potential electrolyte disturbances and renal function deterioration.

Relevant Studies

• A study from 1978 3 reported severe electrolyte disturbances in patients using metolazone and furosemide, highlighting the need for caution when using diuretic combinations.
• A 2013 case report 4 described the successful use of triple diuretics (furosemide, metolazone, and spironolactone) in conjunction with an aquaretic in patients with acute decompensated heart failure, with close supervision by cardiologists and nephrologists.
• A 2017 review 5 emphasized the importance of assessing renal function in patients with liver disease, as both acute kidney injury and chronic kidney disease are common in these patients.
• A 2021 study 6 evaluated the safety and tolerability of spironolactone in patients with heart failure and chronic kidney disease, finding that spironolactone may be safe to initiate in hospitalized patients with close monitoring.
• A 2011 review 7 discussed the use of diuretics in renal disease, highlighting the importance of understanding the patient's response to diuretics and being vigilant for biochemical disturbances.

Key Considerations

• The patient's impaired renal function and prerenal azotemia require careful monitoring of electrolyte levels and renal function when using diuretics.
• The combination of spironolactone and furosemide may increase the risk of electrolyte disturbances, particularly hyperkalemia.
• Close supervision by a healthcare team is essential to adjust medication dosages and frequencies as needed to minimize adverse events.