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Spironolactone in left-sided heart failure: how does it fit in?

The familiar diuretic spironolactone has taken on new life as a treatment for left-sided congestive heart failure. Spironolactone has been shown to decrease mortality in such patients who are New York Heart Association class IV. It can be used in addition to agents such as angiotensin-converting enzyme inhibitors and beta blockers, which also decrease mortality, and diuretics and digoxin, which are useful in treating symptoms. Spironolactone is safe, easy to use and reasonably priced. More research is necessary to determine the order and combinations of these medications in slowing the progression of this disease.

Contraindications↗

Species differences in the metabolism and disposition of spironolactone.

The absorption, excretion and metabolism of [22-14C]spironolactone was compared in Charles River rats, beagle dogs and rhesus monkeys. The drug was administered at the fixed dose of 5 mg/kg po and iv. From the po/iv ratios of the areas under the plasma radioactivity-time curves, the gastrointestinal absorption of the drug was estimated to be 82% in the rat, 62% in the dog, and 103% in the monkey. The absolute bioavailability of a pharmacologically active metabolite, canrenone, was 57% in the dog and 48% in the monkey. Spironolactone was extensively metabolized in all three species and differences existed in the composition of the metabolites in their plasma, urine, and feces. The amount of radioactivity that was excreted in the urine and feces of all three species was similar after either po or iv administration of the drug. The cumulative average excretion of radioactivity in the urine as percentage of the po dose in 6 days was 4.69% in the rat (N = 5), 18.5% in the dog (N = 3), and 46.0% in the monkey (N = 3). In the feces, the corresponding excretion values were 74.2, 69.3 and 40.1%, respectively. Canrenone excretion in the urine constituted 0.65% of the po dose in the rat, 0.82% in the dog, and 5.86% in the monkey, whereas the excretion of total fluorogenic metabolites constituted 1.1, 1.9, and 12.1% respectively. Comparison of animal data with those published for humans indicated that the disposition and metabolism of spironolactone in the rhesus monkey, rather than those in the rat or the dog, was closest to that in man.

Animals↗

Spironolactone improves cardiac sympathetic nerve activity and symptoms in patients with congestive heart failure.

UNLABELLED: We evaluated whether spironolactone would improve cardiac sympathetic nerve activity and symptoms in patients with congestive heart failure (CHF). METHODS: Thirty patients with CHF (left ventricular ejection fraction [LVEF] < 40%; mean, 30% +/- 9%) were treated with an angiotensin-converting enzyme inhibitor, a loop diuretic, and, in most cases, digoxin. Fifteen patients (group A) were assigned to additionally receive spironolactone (12.5-50 mg/day), and the remaining 15 patients (group B) continued their current regimen. Patients were studied before and 6 mo after treatment. The delayed heart-to-mediastinum count ratio (H/M ratio), delayed total defect score (TDS), and washout rate (WR) were determined from (123)I-meta-iodobenzylguanidine (MIBG) images. LVEF was determined by echocardiography, and New York Heart Association (NYHA) functional class was estimated. RESULTS: Before treatment, LVEF, TDS, H/M ratio, WR, and NYHA functional class were similar in both groups. With treatment, LVEF did not significantly improve in either group. However, after treatment in group A, TDS decreased from 37 +/- 9 to 25 +/- 13 (P = 0.0001), H/M ratio increased from 1.62 +/- 0.20 to 1.83 +/- 0.27 (P < 0.0001), and WR decreased from 51 +/- 9 to 40 +/- 15 (P < 0.001). In group B, these parameters did not significantly change. NYHA functional class improved in both groups (in group A, from 3.3 +/- 0.5 to 1.7 +/- 0.5 [P < 0.0001]; in group B, from 3.3 +/- 0.5 to 2.4 +/- 0.6 [P = 0.01]); this was a significantly greater improvement in group A than in group B (P < 0.01). CONCLUSION: Spironolactone improves cardiac sympathetic nerve activity and symptoms in patients with CHF.

3-Iodobenzylguanidine↗

Effects of the addition of a low dose of spironolactone on brain natriuretic peptide plasma level and cardiopulmonary function in patients with moderate congestive heart failure.

BACKGROUND: The purpose of our study was to assess the effects of a low dose of spironolactone in patients with moderate congestive heart failure (CHF) on the plasma level of brain natriuretic peptide (BNP), echocardiographic left ventricular ejection fraction (LVEF), and cardiopulmonary function assessed by cardiopulmonary (CP) test. MATERIAL/METHODS: 51 CHF patients (74.5% males, mean age 60 years) underwent transthoracic echocardiography, CP test, and plasma BNP assay at the time of enrollment and after 6 months of standard therapy for CHF plus a low dose of spironolactone (group A). A control group (21 patients, group B) was treated using standard therapy only. All subjects were in NYHA class I-III and had LVEF < or = 40%. RESULTS: BNP concentration decreased significantly (from 45.7+/-57.4 pg/ml to 18.6+/-26.9 pg/ml at follow-up; p=0.01), and the NYHA class and LVEF improved (2.2+/-0.6 vs 1.7+/-0.5, p=0.0001; 27.7+/-7.2% vs 35.1+/-11%, p=0.001 respectively) in subjects in group A. In spite of clinical amelioration, peak oxygen consumption, oxygen pulse and anaerobic threshold in the CP test did not change significantly (16.6+/-5.7 ml/kg/min vs 17.1+/-5.3 ml/kg/min p=0.5; 8.8 +/- 4.3 ml/beat vs 9.5+/-3.6 ml/beat p=0.2; 0.75+/-0.2 ml/Kg/min vs 0.73+/-0.2 ml/Kg/min p=0.7). No differences were noticed in the control group. CONCLUSIONS: The addition of spironolactone reduced the BNP plasma level in patients with moderate CHF and increased LVEF. This therapy improved the NYHA class without modifying the functional parameters in the CP test.

Aged↗

[Long term therapy over nine years with Spironolacton in hydropic cardiac insufficiency].

The effect of the aldosterone-antagonist Spironolacton in decompensated hydropic cardiac insufficiency is explored with patients not re-compensated under a glycosid-diuretica-therapy. This analysis is based on the clinical records and other documents of 34 patients with most serious oedematous cardiac insufficiency of different genesis. For elucidation of the result of the clinical treatment two casuistic cases are described. The probability of mortality or survival-rate is calculated, periods of observation could be achieved up to more than nine years. It is endeavoured to compare the results with observations of patients-collectives, that are known from the literature. Statistically significant decreases in weight are objectified. When examining the reactions of blood-pressure at the Spironolacton-therapy no statistically significant alterations of blood-pressure could be observed with those cardiac-decompensated patients. 6.25 per cent of the considered serum-potassium-data were underneath the limitations of lower standard, at 1.875 per cent of the measured values a hyperkalemia existed. No clinical side-effects could be observed except the incidence of a gynaecomastia with two male patients. A protracted therapy with Spironolacton for patients with decompensated hydropical myocardial insufficiency is appropriated to support recompensation in addition to the hitherto conventional possibilities of therapy, and to maintain this achieved re-compensation.

Aged↗

Reduction in hepatic venous pressure gradient as a consequence of volume contraction due to chronic administration of spironolactone in patients with cirrhosis and no ascites.

The effect of plasma volume contraction induced by a 4-wk administration of spironolactone or furosemide on the hepatic venous pressure gradient was evaluated in consecutively allocated patients with cirrhosis and no ascites. In the spironolactone group (n = 15), the hepatic venous pressure gradient decreased significantly (p less than 0.005), by 21.8%, with a significant contraction of circulating plasma volume (p less than 0.01). Although there were no statistically significant correlations between the change in hepatic venous pressure gradient and changes in circulating plasma volume or in simultaneously determined systemic hemodynamics, a significant negative correlation (r = -0.74, p less than 0.01, n = 12) between the hepatic venous pressure gradient change and the post-treatment plasma aldosterone levels was found. However, in the furosemide group (n = 10), the hepatic venous pressure gradient and circulating plasma volume did not significantly decrease. Our data demonstrated a significant reduction in the hepatic venous pressure gradient on a chronic administration of spironolactone, which may have been due to volume contractions in patients with cirrhosis and no ascites.

Adult↗

[Treatment of hirsutism with spironolactone and progestagen combination].

The antiandrogenic activity of spironolactone was used for treating hirsutism in 76 women, 29 of whom also had acne. Midcycle vaginal bleeding was observed in 21 patients under spironolactone 75 mg per day. This side-effect disappeared after a progestagen administered 10 days each month was added to the treatment. With this combination, spironolactone was well tolerated and effective in treating acne within the first months of administration, but in 61 percent of the patients at least 6 months were required to improve hirsutism.

Acne Vulgaris↗

Hirsutism--a low dose spironolactone therapy.

Total testosterone, dehydroepiandrosterone sulfate, prolactin and estradiol were assayed in 78 women, clinically divided into idiopathic hirsutism (I. H.)-17 women and polycystic ovary syndrome (PCO) - 61 women, with the latter group having menstrual irregularity dating almost back to the menarche. The serum testosterone measurement was found to be not sensitive in detecting abnormalities in testosterone production. Only 24 (39%) of the women with polycystic ovary syndrome and 5 (29%) of the women with idiopathic hirsutism had elevated serum testosterone. In statistical analysis the serum testosterone was greater (P less than 0.05) in women with polycystic ovary syndrome without hirsutism than in idiopathic hirsutism and PCO with hirsutism. There were not significant differences between the mean levels of prolactin, dehydroepiandrosterone sulfate and estradiol. Twelve women, with hirsutism, were treated with low dose spironolactone (75 mg daily) for six months. There was an excellent clinical response in 7 (58%), incomplete response in one, no response in 4 women. Two patients dropped out of the trial because of ineffectiveness of the therapy after three months. Side effects were not major problem. Spironolactone caused statistically significant reduction in testosterone values after 6 months of treatment. Our results demonstrate that low-dose spironolactone is effective in the treatment of hirsutism.

Adolescent↗

Low-dose spironolactone in the treatment of female hirsutism.

Twelve women, 11 with hirsutism and one with alopecia areata, were treated with low-dose spironolactone (50 mg daily) from the 4th until the 22nd cycle day over 12 consecutive menstrual cycles. Eight hirsute women observed a favorable effect on hirsutism in 3 to 8 months, and hair loss ceased in the one patient with alopecia areata. No significant side effects occurred. Low-dose spironolactone decreased the concentration of total and free testosterone and elevated the concentration of prolactin on the 10th cycle day, while LH, FSH, estradiol, progesterone, DHEAS, SHBG, and cortisol levels remained unchanged. The plasma aldosterone concentration increased significantly during the treatment, although serum potassium and sodium concentrations remained unchanged. Low-dose spironolactone is, thus, safe and effective in the treatment of hirsutism. It seems to be useful as an initial or alternative treatment.

Acne Vulgaris↗

Successful treatment of hyperkalemic quadriplegia associated with spironolactone.

Hyperkalemic flaccid quadriplegia and cardiotoxic disturbances developed during antihypertensive therapy with spironolactone in a 76-year-old woman with chronic renal insufficiency. Hyperkalemia was successfully overcome and followed by the disappearance of all cardiac and muscular disorders. Progression of the renal disease leading to a decrease of creatinine clearance from 85 ml/min to 4.5 ml/min, during a three-year observation period per se had apparently no influence on the serum level of potassium. Our studies suggested that no primary insufficiency of the renin-aldosterone and glucocorticoid systems had been responsible for the hyperkalemia, therefore, it could be contributed entirely to the effect of spironolactone abolishing the K+ secreting capacity of the already decreased renal mass. Further studies revealed that blocking action of the drug on H+ secretion ("renal tubular acidosis") may also have had a role-in addition to the K+ retention-in the development of the spironolactone-induced hyperkalemia.

Acid-Base Equilibrium↗

The effect of oral spironolactone and intravenous canrenoate-K on the digoxin radioimmunoassay.

Twenty patients receiving a constant maintenance therapy of digoxin preparations were selected, and daily plasma digoxin concentrations were measured using the clinical assays gammacoat 125I-digoxin radioimmunoassay. A single intravenous dose of canrenoate-K was given to 10 patients, thus producing after 5 min. a rapid rise of plasma digoxin concentrations, which varied from 121.1 to 214.3% of the baseline value (100%). In 3 of these patients, plasma digoxin concentrations were measured serially over a period of 8 hrs. and yielded digoxin levels of 81.5, 112.5 and 122.5% of the baseline value. The other 10 patients received an oral dose of 100 mg spironolactone twice a day, and plasma digoxin determinations were carried out daily. Up to the fifth day, a continuous rise of average digoxin levels was found (on day 5, 181.0%) as long as digoxin and spironolactone were continued. From the sixth to the ninth day of therapy, average mean values remained fairly constant (on days 6-9, 168.9, 173.6, 170.8, 172.5% respectively). Contradictory results have been obtained when the interference of spironolactone, canrenone or canrenoate-K on the radioimmunoassay was studied [1, 2]. This study is a further contribution for evaluating the specifity a commercially available 125J-labeled digoxin kit.

Canrenoic Acid↗

Comparison of chlorthalidone and spironolactone in low--renin essential hypertension.

Nineteen patients with uncomplicated essential hypertension and low activity of plasma renin in response to a change from recumbency to an upright posture along with furosemide administration were given spironolactone, 400 mg/d, or chlorthalidone, 100mg/d, in a double-blind, random-sequence, crossover trial. The sequence of treatments was placebo for 2 months, one active drug for 2 months, placebo again for 1 month and the other active drug for 2 months. With both active treatments the average systolic, diastolic and mean arterial pressures decreased significantly. The two agents were equally efficacious in lowering the blood pressure regardless of the severity of hypertension during placebo treatment. Body weight, 24--hour urinary excretion of sodium, the plasma renin activity and the plasma aldosterone level at the end of the initial placebo period did not allow us to predict the response to either drug. Both drugs reduced the body weight and increased the stimulated plasma renin level activity. Chlorthalidone significantly increased the serum uric acid level and significantly reduced the serum potassium level. Three patients experienced orthostatic dizziness during spironolactone therapy, but no adverse symptoms were observed with chlorthalidone therapy. Thus, spironolactone is an effective alternative to thiazide-type drugs in patients with low-renin essential hypertension.

Adult↗

Glucuronidation and elimination of diflunisal in the isolated perfused rat liver: effect of pretreatment with phenobarbitone, clofibric acid and spironolactone.

The effects of pretreatment of rats with phenobarbitone, clofibric acid and spironolactone on the metabolism and biliary excretion of the salicylate derivative diflunisal have been studied using the isolated perfused liver. The clearance of diflunisal was increased significantly by pretreatment with each of the drugs. Biliary excretion of diflunisal acyl and phenolic glucuronides followed apparent first-order and Michaelis-Menten kinetics, respectively. Pretreatment with clofibric acid or spironolactone resulted in a significant increase in the biliary excretion of the phenolic glucuronide. Pretreatment with phenobarbitone or spironolactone enhanced biliary excretion of the acyl glucuronide, particularly during the first 2 hr. The concentration of the phenolic glucuronide in the perfusate increased steadily during the 6 hr perfusions, whereas the acyl glucuronide concentration was relatively stable, reflecting the ease of hydrolysis of acyl glucuronides under physiological conditions.

Animals↗

Spironolactones and glomerular filtration.

For pharmacologic screening to identify hyperaldosteronism in patients after renal transplantation, spironolactone (Soludactone, Searle) was administered intravenously in 12 subjects (mean dose 1.2 g in the course of 3 days). After its administration a decrease in glomerular filtration rate was assessed when measured by chromogen clearance. Simultaneous measurement of creatinine showed no change, nor was there any change in the plasma level and excretion fraction of urea. The decrease in chromogen clearance was due to an increase in plasma level of the chromogen. Thus the decrease in its clearance was an artifact resulting most probably from the reaction of spironolactone metabolites with alkaline picrate, which was used for the determination of chromogen. In addition to the causes of the glomerular filtration rate decrease after spironolactone which have been reported in the literature - volume depletion and direct influence on the kidneys - the possibility of a fictive decrease must be taken into consideration.

Adult↗

A double-blind comparison of spironolactone and hydrochlorothiazide in hypertensive patients treated with metoprolol.

The antihypertensive effects of hydrochlorothiazide and spironolactone when added to treatment with metoprolol were compared in a double-blind trial comprising 55 previously untreated patients with essential hypertension. Twenty-four patients became normotensive on metoprolol alone, whereas ten patients were randomized to additional therapy with hydrochlorothiazide and ten to spironolactone. Eleven patients dropped out of the trial. Spironolactone was significantly more effective than hydrochlorothiazide as regards reduction of the diastolic blood pressure, Side effects were few and mild during all phases of the study.

Adult↗

Digitoxin metabolism by rat, mouse, and rabbit: NADPH requirement and spironolactone effect.

Digitoxin metabolism in rat, mouse, and rabbit liver homogenates was compared. The rabbit metabolized the compound most extensively, yielding digitoxigenin as major hydrolysis product. Rat and mouse both produced digitoxigenin bisdigitoxoside as major product. Metabolite formation was enhanced by NADPH in all three species. Spironolactone induced the hydrolysis of digitoxin in the rat, but had no effect in the mouse or rabbit. The mechanism of the protective effect of spironolactone in the mouse does not involve induction of digitoxin hydrolysis; in the rabbit, rapid inactivation of spironolactone accounts for the lack of induction.

Animals↗

The effect of spironolactone of the rat uterus.

Isolated rat uterus preparations were used in this study. Ritodrine hydrochloride (Rit), isoxsuprine (Isox), and spironolactone (SP) were applied on the uterus which has spontaneous activity. In similar doses they produced various inhibitory effects. Also, when oxytocin (Oxt) or acetylcholine (Ach) was conducted to the isolated preparations, contractions with high tonus and low amplitude occurred. On this model we investigated the inhibitory effect of spironolactone on the contractions. We conclude that spironolactone can be utilized on the uterus as a uterine contraction inhibitory agent in well regulated doses.

Acetylcholine↗

Combined therapy of captopril and spironolactone for refractory congestive heart failure.

It is traditionally considered that angiotensin--converting enzyme inhibitor (ACEI) and spironolactone could not be used simultaneously because of the assumed risk of hyperkalemia. However, despite ACEI therapy edema and congestive status remain in some of the patients with severe congestive heart failure (CHF). In order to seek an effective therapy for these patients, we observed the efficacy and safety of captopil plus spironolactone in patients with refractory CHF, with strict monitoring of renal function, serum and urine electrolytes and blood pressure (BP). Thirty-five patients with refractory CHF and New York Heart Association functional class IV without renal dysfunction, hypotension and hyperkalemia, whose plasma aldosterone (ALD) level in 88.6% of them was above normal value, were randomly assigned to group A (n = 16, captopril alone) and B (n = 19, captopril plus spironolactone) for a 4-week treatment. The dosage of both drugs was individually adjusted in time according to the results of serum potassium and renal function. The improvement in dyspnea--fatigue ratings, urinary volume and Na+/K+ ratio in group B was more significant than that in group A, and the plasma ALD level in group B decreased obviously while it remained high in group A after therapy. Two patients in group B who had had normal plasma ALD level with urinary Na+/K+ ratio > 1.0 before the therapy did not exhibit any clinical improvement. A strong negative correlation was found between plasma ALD level and urinary Na+/K+ ratio (correlation coefficient -0.689, P < 0.01). None of the patients had obvious hyperkalemia and hypoaldosteronism.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗