Spironolactone for Vertigo
Spironolactone is not recommended for the treatment of vertigo, as there is no evidence supporting its use for this indication, and it is not approved or studied for vestibular disorders.
Evidence Base for Spironolactone
Spironolactone is a potassium-sparing diuretic with well-established FDA-approved indications including heart failure with reduced ejection fraction, resistant hypertension, and ascites in cirrhosis 1, 2. The drug works by antagonizing aldosterone at the distal renal tubule 1.
Off-label uses with some evidence include acne vulgaris and central serous chorioretinopathy, but vertigo is not among them 1, 2. The comprehensive guidelines and drug information available make no mention of spironolactone for any vestibular or balance disorder 1, 2.
Diuretics for Vertigo: The Evidence
While diuretics as a class have been used for Ménière's disease (a specific cause of episodic vertigo), the evidence is weak and controversial:
A 2016 systematic review found that 79% of studies reported improvement in vertigo episodes with various diuretics, but all studies were low-quality evidence (level 4 or lower) 3.
The diuretics studied included hydrochlorothiazide, acetazolamide, chlorthalidone, and isosorbide—but not spironolactone 3.
A 2018 meta-analysis concluded that the certainty of evidence for diuretics in Ménière's disease is "very low," making it unclear whether they provide any benefit 4.
Some experts have raised concerns that diuretics may actually cause harm by inducing abrupt blood pressure drops, potentially triggering ischemia in the inner ear's terminal vascular supply 5.
Treatment Approach for Vertigo
The appropriate pharmacological management depends on the underlying cause 6, 7:
For Ménière's disease:
- Salt restriction and high water intake are first-line non-pharmacological measures 7
- If diuretics are considered, hydrochlorothiazide or acetazolamide have more evidence than spironolactone 3
- Betahistine is commonly used despite limited evidence 7
- Vestibular suppressants (anticholinergics, benzodiazepines) for acute episodes only 6
For vestibular neuritis:
- Brief use of vestibular suppressants (anticholinergics, benzodiazepines) 6
- Early vestibular rehabilitation therapy 6
For vestibular migraine:
- Calcium channel antagonists, tricyclic antidepressants, or beta-blockers for prophylaxis 6
For benign paroxysmal positional vertigo (BPPV):
- Physical therapy maneuvers (Epley, Semont); no drug therapy recommended 6
Critical Safety Considerations if Spironolactone Were Used
If a clinician were to consider spironolactone off-label for any reason in a patient with vertigo, the following monitoring would be essential:
- Baseline and serial monitoring of serum potassium and creatinine at 1 week, 4 weeks, then monthly for 6 months 2
- Hyperkalemia risk is significant, particularly in elderly patients, those with diabetes, kidney disorders, or liver disease 2
- Stop immediately if potassium ≥6.0 mmol/L or creatinine >310 μmol/L (3.5 mg/dL) 2
- Common side effects include headache, dizziness, fatigue, and menstrual irregularities—symptoms that could confound vertigo assessment 1, 2
Common Pitfalls to Avoid
- Do not prescribe spironolactone for vertigo simply because it is a diuretic—the evidence for any diuretic in vertigo is very weak, and spironolactone specifically has never been studied for this indication 3, 4
- Do not assume all diuretics are interchangeable—if a diuretic is to be used for Ménière's disease, hydrochlorothiazide or acetazolamide have marginally more evidence 3
- Avoid prolonged vestibular suppressants—they may impair central compensation and delay recovery 6
- Consider that dizziness from spironolactone itself (occurring in 3-4% of patients) could worsen the clinical picture 1