What is the recommended starting dose of Aldactone (spironolactone) for patients with chronic liver disease?

Aldactone (Spironolactone) Dosing in Chronic Liver Disease

The recommended initial dose of spironolactone for patients with chronic liver disease is 50-100 mg/day, which can be progressively adjusted up to a maximum of 400 mg/day based on response and tolerability. 1

Initial Dosing Algorithm

1. Starting dose options:

   • Standard initial dose: 100 mg/day 1
   • Conservative initial dose: 50 mg/day 1
   • For patients with renal impairment (eGFR 30-50 mL/min/1.73m²): Consider starting at 25 mg/day or every other day 2

2. Dose titration:

   • Increase dose gradually in a stepwise fashion
   • Allow at least 72 hours between dose adjustments (due to long half-life) 1
   • Monitor response based on weight loss and sodium excretion
   • Maximum dose: 400 mg/day 1

Monitoring Parameters

• Electrolytes: Particularly potassium and sodium
• Renal function: Serum creatinine
• Weight: Daily monitoring to assess response
• Timing: Check labs at baseline, 1 week after initiation, and regularly thereafter

Combination Therapy Considerations

• Spironolactone monotherapy is often sufficient for first episodes of ascites 1
• For long-standing or refractory ascites, combination with loop diuretics is recommended 1
• When combining with furosemide, a ratio of 100 mg spironolactone to 40 mg furosemide is typically used 1, 3

Dose Adjustment Based on Response

• Inadequate response: Increase dose every 3-5 days until desired effect or maximum dose reached
• Target weight loss: 0.5 kg/day in patients without peripheral edema 1
• For patients with peripheral edema: No strict limit on daily weight loss, but should be monitored carefully 1

Special Considerations

• Renal impairment: Use lower doses and monitor renal function closely
• Gynecomastia: Consider switching to amiloride (10-40 mg/day) if painful gynecomastia develops 1
• Hyperkalemia: If potassium rises above 5.5 mmol/L, reduce dose or discontinue 1

Contraindications and Precautions

• Severe renal impairment: eGFR <30 mL/min/1.73m²
• Hyperkalemia: Serum potassium >5.0 mmol/L
• Concomitant medications: Use caution with ACE inhibitors, ARBs, and potassium supplements

Common Pitfalls to Avoid

1. Overly rapid dose escalation: Always wait at least 72 hours between dose adjustments due to spironolactone's long half-life 1
2. Inadequate monitoring: Failure to check electrolytes and renal function can lead to serious complications
3. Excessive sodium restriction: Sodium restriction should be moderate (2g/day) to avoid malnutrition 1
4. Ignoring gynecomastia: This common side effect can significantly impact quality of life and may require switching to amiloride 1

In patients with cirrhosis and relatively refractory ascites, higher doses of spironolactone (300-600 mg daily) have been shown to be effective, but require careful monitoring for hyperkalemia and other adverse effects 4.