What is the optimal treatment approach for an 81-year-old female patient with congestive heart failure (CHF), well-controlled diabetes mellitus, and well-controlled hypertension, presenting with impaired renal function, on metoprolol (Lopressor) 50 mg, furosemide (Lasix) 20 mg daily, apixaban (Eliquis) 5 mg daily, lisinopril (Zestril) 40 mg daily, and empagliflozin (Jardiance) 10 mg daily, with hyperkalemia, currently holding spironolactone (Aldactone) 25 mg?

From the Guidelines

For this 81-year-old female with CHF, controlled diabetes and hypertension, I recommend resuming spironolactone at a reduced dose of 12.5 mg daily once potassium normalizes below 5.0 mEq/L, with weekly potassium monitoring initially, as suggested by the guidelines for the diagnosis and treatment of chronic heart failure 1. Her current regimen of metoprolol 50 mg, furosemide 20 mg, apixaban 5 mg, lisinopril 40 mg, and jardiance 10 mg should be continued as these medications provide important cardioprotective benefits.

Key Considerations

• The elevated creatinine (1.61) indicates reduced kidney function, which contributes to potassium retention, and requires careful monitoring when using spironolactone, as noted in the guidelines for the diagnosis and treatment of chronic heart failure 1.
• Spironolactone offers mortality benefit in CHF but requires careful monitoring in this setting, particularly with regard to potassium levels and renal function, as emphasized in the comprehensive guidelines for the diagnosis and treatment of chronic heart failure 1.
• The combination of an ACE inhibitor (lisinopril) with spironolactone increases hyperkalemia risk, but both medications provide significant benefit for her heart failure, and their use should be guided by the principles outlined in the guidelines for the management of heart failure 1.
• Jardiance helps with both diabetes control and heart failure and has renal protective effects, making it a valuable component of her treatment regimen.

Management of Hyperkalemia

• Consider adding patiromer or sodium zirconium cyclosilicate if hyperkalemia persists despite dose reduction of spironolactone, as these agents can help manage potassium levels.
• If hyperkalemia continues to be problematic, consider reducing the lisinopril dose before permanently discontinuing spironolactone, weighing the benefits and risks of each medication in the context of her overall health status, as informed by the guidelines for the diagnosis and treatment of chronic heart failure 1.

From the FDA Drug Label

Spironolactone can cause hyperkalemia. 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 [see Drug Interactions (7. 1)] . Monitor serum potassium within 1 week of initiation or titration of spironolactone and regularly thereafter. If hyperkalemia occurs, decrease the dose or discontinue spironolactone and treat hyperkalemia.

The patient has impaired renal function with a creatinine level of 1.61 and is at risk for hyperkalemia. The patient is also taking lisinopril, an angiotensin-converting enzyme inhibitor, which increases the risk of hyperkalemia. Given the patient's hyperkalemia is improving at 5.5, it is likely that holding spironolactone was an appropriate decision. Restarting spironolactone should be done with caution, and the patient's serum potassium should be closely monitored. It is recommended to decrease the dose or discontinue spironolactone if hyperkalemia occurs again. 2 The patient's renal function should also be monitored periodically due to the risk of worsening renal function, particularly with concomitant use of nephrotoxic drugs. 2

From the Research

Patient Profile

• 81-year-old female patient with congestive heart failure (CHF)
• Well-controlled diabetes and hypertension (108/69 mmHg)
• Creatinine level: 1.61 mg/dL
• Currently on metoprolol 50 mg, furosemide 20 mg daily, apixaban 5 mg daily, lisinopril 40 mg daily, and jardiance 10 mg daily
• Typically on spironolactone 25 mg, but currently holding due to hyperkalemia (potassium level: 5.5 mEq/L)

Hyperkalemia Management

• According to 3, hyperkalemia is a potentially fatal electrolyte disorder that can lead to adverse outcomes, especially due to severe cardiac arrhythmias
• The study suggests that potassium is a predictor of mortality and should be monitored closely in patients at risk for hyperkalemia
• 4 discusses the clinical manifestations of hyperkalemia and outlines an approach to its diagnosis and treatment, including the importance of identifying the underlying cause of hyperkalemia

Spironolactone Use in CHF Patients

• 5 evaluates the safety and tolerability of spironolactone in patients with heart failure and chronic kidney disease, suggesting that spironolactone may be safe to initiate in hospitalized patients with HF and CKD
• However, 6 warns that the combination of ACE inhibitors and spironolactone should be used with caution and monitored closely in patients with renal insufficiency, diabetes, older age, worsening heart failure, and those at risk for dehydration
• 7 reports that spironolactone-induced hyperkalemia and renal insufficiency are more common in clinical practice than previously reported, especially in patients with comorbidities such as diabetes and those taking beta-blockers

Considerations for This Patient

• Given the patient's hyperkalemia and renal insufficiency, it is essential to monitor her potassium levels closely and adjust her medication regimen accordingly
• The patient's age, diabetes, and use of beta-blockers may increase her risk for hyperkalemia and renal insufficiency, as reported in 6 and 7
• The decision to restart spironolactone should be made cautiously, taking into account the patient's current potassium level and renal function, as well as the potential benefits and risks of spironolactone therapy in patients with CHF and CKD, as discussed in 5 and 6