Can spironolactone be used to treat Hypertension (HTN)?

From the Guidelines

Spironolactone can be used for hypertension, particularly in cases of resistant hypertension, as an add-on therapy to existing antihypertensive regimens, typically at doses of 25-50 mg daily, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.

Key Considerations

• Spironolactone is most effective for resistant hypertension, especially in patients with primary aldosteronism or low-renin hypertension.
• When initiating treatment, start with 25 mg once daily and monitor potassium levels and renal function after 1-2 weeks, then periodically thereafter.
• Dose adjustments can be made based on blood pressure response and laboratory values.
• Common side effects include hyperkalemia, gynecomastia in men, and menstrual irregularities in women.
• Spironolactone should be avoided in patients with severe renal impairment (eGFR <30 mL/min) or hyperkalemia.

Mechanism and Efficacy

• Spironolactone works as an aldosterone antagonist, blocking mineralocorticoid receptors in the distal tubule of the kidney, promoting sodium and water excretion while retaining potassium, thus reducing blood volume and blood pressure.
• The 2024 ESC guidelines recommend the addition of low-dose spironolactone to existing treatment for resistant hypertension 1.
• Other studies have also demonstrated the effectiveness of spironolactone in reducing blood pressure in patients with resistant hypertension, including a study published in 2008 by the American Heart Association 1.

Comparison with Other Treatments

• Spironolactone has been compared to other treatments, such as amiloride, and has been shown to be effective in reducing blood pressure, although amiloride may be more effective in some cases 1.
• The choice of spironolactone or other treatments should be based on individual patient characteristics and medical history.

Monitoring and Follow-up

• Regular monitoring of potassium levels and renal function is necessary when using spironolactone, especially in patients with pre-existing renal impairment or those taking other medications that affect potassium levels.
• Blood pressure should be regularly monitored to assess the effectiveness of spironolactone and adjust the dose as needed.

From the FDA Drug Label

1.2 Hypertension

Spironolactone tablets are indicated as add-on therapy for the treatment of hypertension, to lower blood pressure in patients who are not adequately controlled on other agents.

Yes, spironolactone can be used for the treatment of hypertension, specifically as add-on therapy to lower blood pressure in patients who are not adequately controlled on other agents 2.

• It is used to reduce the risk of fatal and nonfatal cardiovascular events, primarily strokes and myocardial infarctions.
• The goal is to achieve blood pressure control as part of comprehensive cardiovascular risk management.

From the Research

Spironolactone for Hypertension Treatment

• Spironolactone, a mineralocorticoid receptor antagonist, has been used in the treatment of hypertension for over 50 years 3.
• It has a secure and stable position in the treatment of resistant hypertension, with several studies demonstrating its effectiveness in lowering blood pressure 3, 4, 5.
• The addition of spironolactone to antihypertensive combination therapy has been shown to have a significant effect on blood pressure lowering in several uncontrolled trials and randomized studies, including the ASCOTBPLA and PATHWAY-2 studies 3.
• A randomized, double-blind, placebo-controlled trial (ASPIRANT) found that the addition of 25 mg of spironolactone to patients with resistant arterial hypertension resulted in a significant decrease in systolic blood pressure [-5.4 mm Hg, 95%CI -10.0; -0.8] 5.

Benefits and Risks

• Spironolactone has been shown to reduce morbidity and mortality in patients with chronic heart failure, particularly those with reduced ejection fraction 3, 6.
• However, the use of spironolactone in combination with ACE inhibitors can increase the risk of hyperkalemia, particularly in patients with renal insufficiency, diabetes, or older age 7.
• The daily dose of spironolactone should not exceed 25 mg to minimize the risk of hyperkalemia 7.
• Common adverse effects of spironolactone include gynecomastia, decreased libido, and impotence in men, as well as menstrual irregularities in women 6.

Clinical Guidelines

• Current guidelines reflect the importance of spironolactone in the treatment of resistant hypertension, primary hyperaldosteronism, and heart failure with reduced ejection fraction 3.
• Spironolactone is considered an appropriate antihypertensive medication to add to the treatment of patients with resistant hypertension who are not at their blood pressure goal 4.