How does spironolactone (an aldosterone antagonist) help in the management of liver cirrhosis?

From the Guidelines

Spironolactone is the primary treatment for managing ascites in liver cirrhosis, and it should be initiated at a dose of 100 mg daily, with a maximum dose of 400 mg daily, as it has been shown to be effective in reducing sodium and water retention in the body while preserving potassium levels 1. The mechanism behind spironolactone's benefit relates to the pathophysiology of cirrhosis, where portal hypertension leads to sodium retention and fluid accumulation. By counteracting the hyperaldosteronism common in cirrhosis, spironolactone helps restore a more normal fluid balance. Some key points to consider when using spironolactone for liver cirrhosis include:

• Spironolactone is often combined with loop diuretics like furosemide (starting at 40 mg daily) for enhanced effect 1.
• Patients should be monitored for potential side effects including hyperkalemia, gynecomastia in men, and worsening kidney function 1.
• Dietary sodium restriction (typically 2000 mg/day) should accompany spironolactone therapy for optimal management of ascites in cirrhosis 1.
• Diuretic-induced weight loss should not exceed 0.5 kg/day in patients without peripheral oedema, and 1 kg in the presence of peripheral oedema 1. It's worth noting that the most recent and highest quality study 1 supports the use of spironolactone as the first-line diuretic for managing ascites in liver cirrhosis, and it provides guidance on the optimal dosing and monitoring strategies.

From the FDA Drug Label

1. 3 Edema Associated with Hepatic Cirrhosis or Nephrotic Syndrome Spironolactone tablets are indicated for the management of edema in the following settings: Cirrhosis of the liver when edema is not responsive to fluid and sodium restriction

Spironolactone helps liver cirrhosis by managing edema associated with the condition, specifically when edema is not responsive to fluid and sodium restriction.

• It is used to treat edema in patients with liver cirrhosis.
• The drug is particularly useful when other diuretics have caused hypokalemia. 2

From the Research

Mechanism of Spironolactone in Liver Cirrhosis

• Spironolactone is a potassium-sparing diuretic that helps eliminate ascites in patients with liver cirrhosis by enhancing sodium excretion 3, 4.
• The drug works by antagonizing the effect of aldosterone, a hormone that promotes sodium retention in the body 4.
• Spironolactone is often used in combination with furosemide, a loop diuretic, to treat ascites in patients with liver cirrhosis 3, 5.

Efficacy of Spironolactone in Treating Ascites

• Studies have shown that spironolactone is effective in eliminating ascites in patients with liver cirrhosis, with response rates ranging from 90% to 98% 3, 5.
• Spironolactone has been shown to be as effective as furosemide in treating ascites, and may be preferred due to its lower risk of side effects 5.
• High-dose spironolactone therapy (300-600 mg daily) has been shown to be effective in patients with relatively refractory ascites 6.

Comparison with Other Diuretics

• Spironolactone has been compared to eplerenone, another potassium-sparing diuretic, in the management of ascites in patients with liver cirrhosis 7.
• Both spironolactone and eplerenone were found to be effective in reducing ascites, but eplerenone had a better side effect profile, with less incidence of gynecomastia and hyperkalemia 7.

Dosage and Administration

• The recommended initial dose of spironolactone for treating ascites in patients with liver cirrhosis is 100-200 mg daily, with a maximum dose of 400 mg daily 3.
• Patients with mild ascites may be treated initially with diuretics, while those with more severe ascites may require therapeutic paracentesis followed by diuretic therapy 4.