Can Spironolactone Be Given?
Yes, spironolactone can be given for multiple indications including heart failure, hypertension, acne, and hirsutism, but requires careful patient selection, appropriate dosing, and vigilant monitoring for hyperkalemia and renal function. 1, 2
Clinical Indications and Dosing
Heart Failure (NYHA Class III-IV)
- Start at 12.5-25 mg daily in patients with severe heart failure already on ACE inhibitors, diuretics, and digoxin 1
- Reduces mortality by 30% and hospitalizations by 35% when added to standard therapy 3
- Target dose is 25-50 mg once daily 1
Acne and Hirsutism
- Start at 50-100 mg daily for acne treatment 1
- Effective dose range is 50-200 mg daily, with 75% achieving improvement at 50 mg daily combined with benzoyl peroxide 1
- For hirsutism, 100-150 mg daily shows 85% improvement rates 4
- Must be combined with oral contraceptives to prevent pregnancy and reduce menstrual irregularities 1, 4, 5
Hypertension
- Doses of 100-500 mg/day effectively lower blood pressure by approximately 20/7 mmHg 6
- Doses above 50 mg/day show no additional benefit 6
Absolute Contraindications
Do not give spironolactone if:
- Pregnancy (risk of feminization of male fetus) 1, 5, 2
- Acute renal failure or anuria 5, 2
- Creatinine clearance <30 mL/min 1
- Baseline potassium >5.0-5.5 mEq/L 1, 2
- Addison's disease 5
- Concomitant use of eplerenone or triamterene 5
Critical Monitoring Requirements
Initial Monitoring (First 3 Months)
- Check potassium and creatinine within 3 days, then at 1 week after initiation 1
- Continue monthly monitoring for first 3 months 1
- Then every 3 months thereafter 1
High-Risk Patients Requiring Closer Monitoring
- Age >65 years 1
- Creatinine clearance 30-50 mL/min (reduce initial dose to 12.5 mg daily) 1
- Diabetes mellitus, hypertension, chronic kidney disease 1, 7
- Concomitant ACE inhibitors, ARBs, NSAIDs, or digoxin 1
- Patients requiring high-dose diuretics 1
Low-Risk Patients (Monitoring Can Be Less Intensive)
- Young, healthy women without comorbidities do not require routine potassium monitoring 7, 4
- This applies primarily to dermatologic indications (acne/hirsutism) 1, 7
Managing Hyperkalemia
If potassium 5.5-6.0 mEq/L:
- Reduce dose to 25 mg on alternate days 1
- Stop potassium supplementation if being used 1
- Recheck within 3 days 1
If potassium >6.0 mEq/L:
- Discontinue spironolactone immediately 1
- Treat hyperkalemia per standard protocols 2
- Seek specialist advice 1
Common Pitfalls and How to Avoid Them
The "Real-World" Hyperkalemia Problem
- Clinical trials showed 2% hyperkalemia incidence, but population-based studies found 24% incidence in routine practice 1
- After widespread adoption post-RALES trial, hospitalizations for hyperkalemia increased from 2.4 to 11 per 1000 patients 1
- This occurs because real-world patients are less selected than trial populations 1
Drug Interactions to Avoid
- Never combine with potassium supplements or potassium-sparing diuretics 1, 5, 2
- Avoid NSAIDs (including over-the-counter ibuprofen) 1
- Avoid "low-salt" substitutes with high potassium content 1, 4
- Avoid routine triple therapy with ACE inhibitor + ARB + spironolactone 1
Volume Depletion Risk
- Spironolactone can markedly potentiate other diuretics 1
- Instruct patients to temporarily stop during gastroenteritis or vomiting 1
- Monitor for symptomatic hypotension and worsening renal function 2
Side Effects by Frequency
Common (>10%)
- Gynecomastia or breast pain in men: 10% (dose-dependent, usually reversible) 2, 3
- Menstrual irregularities in women: 15-40% (dose-dependent, less common with oral contraceptives) 1, 7
Less Common (1-10%)
- Diuresis: 29% 4
- Breast tenderness/enlargement: 3-17% 7, 4
- Dizziness: 3-4% 7
- Nausea: 2-4% 7
- Fatigue: 1-2% 7
Rare but Serious
- Hyperkalemia requiring hospitalization 1, 2
- Worsening renal function 2
- Hyponatremia, hypomagnesemia, hypocalcemia 2
Special Considerations
Food Effects
- Food increases bioavailability by 95% 2
- Establish consistent pattern of taking with or without food 2
Combination with Drospirenone-Containing Oral Contraceptives
- Safe combination without increased hyperkalemia risk 1, 4
- Provides contraception and reduces menstrual side effects 4, 5