From the Guidelines
Yes, a patient with impaired renal function can be started on spironolactone, but with careful consideration and monitoring.
Key Considerations
- The patient's estimated glomerular filtration rate (eGFR) should be >30 mL/min/1.73 m² and serum potassium <5.0 mEq/L before initiating spironolactone therapy, as recommended by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1.
- Close monitoring of potassium, renal function, and diuretic dosing is essential to minimize the risk of hyperkalemia and worsening renal function 1.
- The starting dose of spironolactone should be 25 mg orally daily, and may be increased to 50 mg daily orally after a month, with dose reduction by half for eGFR 31 to 49 mL/min/1.73 m² 1.
- Regular checks of serum potassium levels and renal function should be performed approximately 1 week, then 4 weeks, then every 6 months after initiating or intensifying MRA therapy, with more frequent testing for clinical instability 1.
Rationale
The use of mineralocorticoid receptor antagonists (MRAs) like spironolactone in patients with heart failure with preserved ejection fraction (HFpEF) may be considered in appropriately selected patients, with careful monitoring of potassium and renal function 1. However, the risk of hyperkalemia and worsening renal function is increased in patients with impaired renal function, and therefore, careful consideration and monitoring are necessary 1.
From the FDA Drug Label
Spironolactone is substantially excreted by the kidney, and the risk of adverse reactions to this drug may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, monitor renal function. Patients with renal impairment are at increased risk of hyperkalemia. Monitor potassium closely. 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
A patient with impaired renal function can be started on spironolactone, but caution is advised. The patient should be closely monitored for signs of hyperkalemia and worsening renal function. Potassium levels should be checked regularly, and the dose of spironolactone may need to be adjusted based on the patient's renal function and potassium levels 2, 2.
From the Research
Patient Selection for Spironolactone Therapy
When considering the initiation of spironolactone in patients with impaired renal function, several factors must be taken into account. These include the patient's estimated glomerular filtration rate (eGFR), potassium levels, and the presence of heart failure.
- Patients with an eGFR > 30 mL/min/1.73 m^2 and potassium < 5.0 mEq/L are generally considered eligible for spironolactone therapy 3.
- However, spironolactone may be prescribed outside these parameters, and its use in patients with chronic kidney disease (CKD) has been evaluated in several studies 4, 5, 6, 7.
Safety and Efficacy of Spironolactone in Impaired Renal Function
The safety and efficacy of spironolactone in patients with impaired renal function have been investigated in various studies.
- A study published in the European journal of clinical pharmacology found that spironolactone may be safe to initiate in hospitalized patients with heart failure and CKD, but larger studies are needed for conclusive results 3.
- Another study published in Cardiorenal medicine found that treatment with spironolactone was associated with improved 2-year survival in heart failure outpatients with renal dysfunction, despite worsened renal function and increased potassium in the spironolactone group 5.
- The ATHENA-HF trial found that high-dose spironolactone did not improve congestion over usual care among patients with acute heart failure, irrespective of renal function and risk factors for diuretic resistance 6.
- A study published in the American heart journal found that spironolactone use was not an independent predictor of all-cause mortality in acute decompensated heart failure patients with severe renal dysfunction, but the clinical benefit of spironolactone use was preserved in certain subgroups 7.
Considerations for Spironolactone Use
When considering the use of spironolactone in patients with impaired renal function, the following factors should be taken into account:
- Close monitoring of potassium levels and renal function is necessary to minimize the risk of hyperkalemia and worsened renal function 4, 5.
- The optimal spironolactone dosage in patients with impaired renal function is not well established, but starting with a low dose and careful uptitration is recommended 4.
- The clinical benefit of spironolactone use in patients with impaired renal function should be assessed on an individual basis, taking into account the patient's underlying condition and other risk factors 7.