Should spironolactone be held before surgery?

From the Guidelines

Spironolactone should typically be continued up to the day of surgery for most patients. The decision to hold or continue spironolactone before surgery should be individualized based on the patient's condition, the type of surgery, and potential risks 1. Spironolactone is a potassium-sparing diuretic that blocks aldosterone receptors, which can affect potassium levels and blood pressure. Continuing it perioperatively helps maintain blood pressure control in hypertensive patients, but sudden discontinuation may lead to rebound fluid retention. If held, potassium levels should be monitored closely, especially if the patient is on other medications affecting potassium.

The European Heart Journal guidelines suggest that diuretics, including spironolactone, can be continued up to the day of surgery and resumed orally when possible 1. However, in patients with heart failure, the dosage of diuretics should be adjusted based on the patient's volume status and symptoms of fluid retention. The guidelines also emphasize the importance of monitoring electrolyte levels, particularly potassium, in patients receiving diuretics.

In certain situations, such as major procedures with significant fluid shifts or in patients at high risk for acute kidney injury or electrolyte disturbances, spironolactone may be held 24-48 hours before surgery 1. The anesthesiologist and surgeon should be informed about the patient's spironolactone use regardless of whether it's continued or held, as it may influence fluid management during surgery. Patients with heart failure, cirrhosis, or hyperaldosteronism may have different considerations regarding perioperative management of this medication.

Some key points to consider when deciding whether to hold or continue spironolactone before surgery include:

• The patient's underlying medical condition, such as heart failure or hypertension
• The type of surgery and potential risks, such as significant fluid shifts or acute kidney injury
• The patient's electrolyte levels, particularly potassium
• The potential for rebound fluid retention if spironolactone is suddenly discontinued
• The need for close monitoring of potassium levels if spironolactone is held.

Overall, the decision to hold or continue spironolactone before surgery should be made on a case-by-case basis, taking into account the individual patient's needs and potential risks.

From the FDA Drug Label

2.5 Treatment of Primary Hyperaldosteronism Administer spironolactone tablets in doses of 100 mg to 400 mg daily in preparation for surgery. The FDA drug label does provide information that spironolactone is used in preparation for surgery for patients with primary hyperaldosteronism, but it does not explicitly state whether to hold spironolactone before surgery. However, based on the information provided, it can be inferred that spironolactone is not required to be held before surgery, as it is administered in preparation for surgery. Key points:

• Spironolactone is used in preparation for surgery for primary hyperaldosteronism.
• The label does not provide explicit instructions to hold spironolactone before surgery. 2

From the Research

Spironolactone and Surgery

• The decision to hold spironolactone before surgery should be based on the patient's individual risk factors and medical history, as there is no straightforward answer to this question 3, 4, 5.
• Patients with heart failure, renal insufficiency, or those taking potassium supplements may be at higher risk of hyperkalemia when taking spironolactone, and serum potassium levels should be monitored closely before and after surgery 3, 4, 5.
• The use of spironolactone in patients with heart failure has been shown to have beneficial effects on morbidity and mortality, but it also increases the risk of hyperkalemia, particularly in patients with renal insufficiency or those taking other medications that affect potassium levels 6, 4, 5.

Risk Factors for Hyperkalemia

• Advanced age, renal insufficiency, potassium supplementation, decompensated congestive heart failure, and a spironolactone dose larger than 25 mg/d increase the risk of hyperkalemia as a consequence of spironolactone therapy 3.
• Patients who develop hyperkalemia are more likely to have diabetes, higher baseline serum potassium levels, and lower baseline potassium supplement doses, and are more likely to be treated with beta-blockers 4.
• The combination of spironolactone and an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker is associated with incremental risk for hyperkalemia 5.

Perioperative Management

• The ALDOCURE trial is currently investigating the use of spironolactone to reduce the incidence of perioperative atrial fibrillation in cardiac surgery patients, and will also monitor safety end points including blood pressure, serum potassium levels, and renal function 7.
• Patients undergoing surgery should have their serum potassium levels monitored closely, and spironolactone should be held or adjusted as necessary to minimize the risk of hyperkalemia 3, 4, 5.