From the Guidelines
Spironolactone is strongly recommended for patients with liver cirrhosis and ascites, typically starting at 100mg daily, which can be increased to 400mg daily if needed, as stated in the most recent guidelines 1. The medication works as a potassium-sparing diuretic that blocks aldosterone receptors, helping to reduce fluid accumulation in the abdomen while maintaining potassium levels. For optimal management of ascites, spironolactone is often combined with furosemide (starting at 40mg daily), maintaining a 100mg:40mg ratio as doses are adjusted, as recommended by recent studies 1. Some key points to consider when using spironolactone for liver cirrhosis and ascites include:
- Patients should have their potassium levels monitored regularly, as hyperkalemia is a potential side effect, and the medication should be used cautiously in patients with kidney dysfunction 1.
- Men may experience gynecomastia with long-term use, and the medication should be temporarily discontinued if serum creatinine rises significantly or if severe hyperkalemia develops 1.
- The medication is most effective when combined with sodium restriction (typically 2g or 90mmol/day) and, in some cases, fluid restriction, as recommended by the American Association for the Study of Liver Diseases 1.
- Patients should weigh themselves daily and report rapid weight changes to their healthcare provider, as this may indicate a need for dose adjustment, and regular monitoring of body weight, serum creatinine, and sodium is necessary to assess response and detect adverse effects 1.
From the FDA Drug Label
3 Edema Associated with Hepatic Cirrhosis or Nephrotic Syndrome Spironolactone tablets are indicated for the management of edema in the following settings: Cirrhosis of the liver when edema is not responsive to fluid and sodium restriction
7 Use in Hepatic Impairment 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. In these patients, initiate spironolactone in the hospital [see Dosage and Administration (2.4) and Clinical Pharmacology (12. 3)] . Clearance of spironolactone and its metabolites is reduced in patients with cirrhosis. In patients with cirrhosis, start with lowest initial dose and titrate slowly [see Dosage and Administration (2.4) and Clinical Pharmacology (12.3)] .
The role of Spironolactone (Aldactone) in the management of Liver Cirrhosis is to manage edema that is not responsive to fluid and sodium restriction. It is essential to initiate Spironolactone in a hospital setting for patients with cirrhosis and ascites, and to start with the lowest initial dose and titrate slowly due to reduced clearance of the drug and its metabolites in these patients 2 2. Key considerations include:
- Monitoring for sudden alterations of fluid and electrolyte balance
- Risk of worsening hepatic encephalopathy and coma
- Reduced clearance of Spironolactone and its metabolites in patients with cirrhosis.
From the Research
Role of Spironolactone in Liver Cirrhosis Management
- Spironolactone is a key drug in the treatment of ascites in cirrhotic patients, with a greater natriuretic potency than loop diuretics in patients with marked sodium retention 3, 4.
- The simultaneous administration of spironolactone and furosemide increases the natriuretic effect of each drug and diminishes their effects on potassium metabolism 3, 5.
- Spironolactone is the basic drug for the treatment of ascites, and diuretics should be given after the elimination of ascites by paracentesis to avoid the reaccumulation of the abdominal fluid 3, 4.
- A combination treatment with furosemide might be necessary in patients who do not respond to spironolactone alone 5.
Comparison with Other Treatments
- Eplerenone and spironolactone are equally effective in management of ascites due to liver cirrhosis, but eplerenone has a better side effect profile 6.
- Therapeutic paracentesis associated with plasma expanders has replaced diuretic therapy as the initial treatment for cirrhotic patients hospitalized with tense ascites, as it is more effective and is associated with a lower rate of complications than diuretic therapy 3, 4.
Treatment Guidelines
- Mild to moderate ascites is treated by salt restriction and diuretic therapy, with spironolactone as the diuretic of choice 5.
- Tense ascites is treated by paracentesis, followed by albumin infusion and diuretic therapy 3, 5.
- Treatment options for refractory ascites include repeated paracentesis and transjugular intrahepatic portosystemic shunt placement in patients with a preserved liver function 5.