From the Guidelines
Discontinuing spironolactone is recommended due to the decline in eGFR from 61 to 50 after its initiation, and instead, adding a beta-blocker such as metoprolol succinate 25-50mg daily can help control blood pressure while addressing possible cardiac rhythm issues. The patient's current regimen includes Perindopril (Angiotensin-Converting Enzyme Inhibitor) 16mg, Amlodipine (Calcium Channel Blocker) 10mg, Indapamide (Thiazide-like Diuretic) 2.5mg, and Spironolactone (Mineralocorticoid Receptor Antagonist) 25mg. However, the decline in eGFR after initiating spironolactone suggests that this medication may be contributing to her renal dysfunction, and its use is cautioned against in patients with significant renal dysfunction 1.
The addition of a beta-blocker such as metoprolol succinate is supported by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension, which recommend the addition of bisoprolol or doxazosin in patients with resistant hypertension 1. Furthermore, the 2020 KDIGO clinical practice guideline recommends the use of renin-angiotensin system inhibitors, such as ACE inhibitors or ARBs, in patients with diabetes, hypertension, and albuminuria, and advises against the combination of ACE inhibitors and ARBs 1.
Key considerations in managing this patient's hypertension include:
- Monitoring renal function and electrolytes closely, particularly potassium levels
- Maintaining a low-sodium diet (less than 2g sodium daily)
- Engaging in regular moderate physical activity as tolerated given her peripheral vascular disease
- Monitoring home blood pressure readings twice daily
- Completing the 24-hour Holter monitoring as planned to evaluate her ectopic atrial rhythm
By discontinuing spironolactone and adding a beta-blocker, while also optimizing her lifestyle and monitoring her condition closely, we can address her resistant hypertension while considering her comorbidities and compromised renal function.
From the FDA Drug Label
5 WARNINGS AND PRECAUTIONS
Warnings and precautions 5.1 Hyperkalemia Spironolactone can cause hyperkalemia. This risk is increased by impaired renal function or concomitant potassium supplementation, potassium-containing salt substitutes or drugs that increase potassium, such as angiotensin converting enzyme inhibitors and angiotensin receptor blockers [see Drug Interactions (7. 1)] . Monitor serum potassium within 1 week of initiation or titration of spironolactone and regularly thereafter. More frequent monitoring may be needed when spironolactone is given with other drugs that cause hyperkalemia or in patients with impaired renal function. If hyperkalemia occurs, decrease the dose or discontinue spironolactone and treat hyperkalemia. 5. 2 Hypotension and Worsening Renal Function Excessive diuresis may cause symptomatic dehydration, hypotension and worsening renal function, particularly in salt-depleted patients or those taking angiotensin converting enzyme inhibitors and angiotensin II receptor blockers. Worsening of renal function can also occur with concomitant use of nephrotoxic drugs (e.g., aminoglycosides, cisplatin, and NSAIDs). Monitor volume status and renal function periodically.
The patient's eGFR decline from 61 to 50 after initiating Spironolactone suggests worsening renal function. Given the patient's impaired renal function and concomitant use of Perindopril (Angiotensin-Converting Enzyme Inhibitor), the risk of hyperkalemia and worsening renal function is increased.
- Monitor serum potassium and renal function more frequently.
- Consider decreasing the dose or discontinuing Spironolactone to prevent further decline in renal function and hyperkalemia 2.
From the Research
Treatment Recommendations
The patient is a 65-year-old woman with poorly managed hypertension, type 2 diabetes mellitus, hyperlipidemia, and peripheral vascular disease. She is currently on Perindopril (Angiotensin-Converting Enzyme Inhibitor) 16mg/Amlodipine (Calcium Channel Blocker) 10mg, Indapamide (Thiazide-like Diuretic) 2.5mg, Spironolactone (Mineralocorticoid Receptor Antagonist) 25mg, with impaired renal function (eGFR decline from 61 to 50) after initiating Spironolactone.
- The patient's current medication regimen includes a combination of antihypertensive agents, which is in line with the recommendations for treating resistant hypertension 3.
- The addition of Spironolactone to the patient's regimen is also supported by the literature, as it has been shown to be effective in treating resistant hypertension 3, 4.
- However, the patient's impaired renal function (eGFR decline from 61 to 50) after initiating Spironolactone is a concern, as it may indicate a need to adjust the medication regimen or monitor the patient's renal function more closely 4, 5.
- The use of Perindopril, Indapamide, and Amlodipine in combination has been shown to be effective in controlling blood pressure and improving health-related quality of life 6, 7.
Considerations for Renal Function
- The patient's eGFR decline from 61 to 50 after initiating Spironolactone may indicate a need to adjust the medication regimen or monitor the patient's renal function more closely 4, 5.
- The literature suggests that Spironolactone may be safe to initiate in patients with heart failure and chronic kidney disease, but careful monitoring of renal function and potassium levels is necessary 5.
- The patient's renal function should be closely monitored, and the medication regimen should be adjusted as needed to minimize the risk of further decline in renal function 4, 5.
Next Steps
- The patient's medication regimen should be reviewed and adjusted as needed to ensure optimal control of blood pressure and minimize the risk of further decline in renal function 3, 6, 4, 7, 5.
- The patient's renal function and potassium levels should be closely monitored, and the medication regimen should be adjusted as needed to minimize the risk of hyperkalemia or further decline in renal function 4, 5.
- The patient should be referred to a hypertension specialist to screen for secondary causes of hypertension and to develop a comprehensive treatment plan 3.