SPIRONOLACTONE- spironolactone tablet
1 INDICATIONS AND USAGE
1.1 Heart Failure
Spironolactone tablets are indicated for treatment of NYHA Class III-IV heart failure and reduced ejection fraction to increase survival, manage edema, and reduce the need for hospitalization for heart failure.
Spironolactone tablets are usually administered in conjunction with other heart failure therapies.
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. Lowering blood pressure reduces the risk of fatal and nonfatal cardiovascular events, primarily strokes and myocardial infarctions. These benefits have been seen in controlled trials of antihypertensive drugs from a wide variety of pharmacologic classes.
Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake. Many patients will require more than one drug to achieve blood pressure goals. For specific advice on goals and management, see published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC).
Numerous antihypertensive drugs, from a variety of pharmacologic classes and with different mechanisms of action, have been shown in randomized controlled trials to reduce cardiovascular morbidity and mortality, and it can be concluded that it is blood pressure reduction, and not some other pharmacologic property of the drugs, that is largely responsible for those benefits. The largest and most consistent cardiovascular outcome benefit has been a reduction in the risk of stroke, but reductions in myocardial infarction and cardiovascular mortality also have been seen regularly.
Elevated systolic or diastolic pressure causes increased cardiovascular risk, and the absolute risk increase per mmHg is greater at higher blood pressures, so that even modest reductions of severe hypertension can provide substantial benefit. Relative risk reduction from blood pressure reduction is similar across populations with varying absolute risk, so the absolute benefit is greater in patients who are at higher risk independent of their hypertension (for example, patients with diabetes or hyperlipidemia), and such patients would be expected to benefit from more aggressive treatment to a lower blood pressure goal.
Some antihypertensive drugs have smaller blood pressure effects (as monotherapy) in black patients, and many antihypertensive drugs have additional approved indications and effects (e.g., on angina, heart failure, or diabetic kidney disease). These considerations may guide selection of therapy.
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.
- Nephrotic syndrome when treatment of the underlying disease, restriction of fluid and sodium intake, and the use of other diuretics produce an inadequate response.
Because it increases serum potassium, spironolactone may be useful for treating edema when administration of other diuretics has caused hypokalemia.
1.4 Primary Hyperaldosteronism
Spironolactone tablets are indicated in the following settings:
- Short-term preoperative treatment of patients with primary hyperaldosteronism.
- Long-term maintenance therapy for patients with discrete aldosterone-producing adrenal adenomas who are not candidates for surgery.
- Long-term maintenance therapy for patients with bilateral micro or macronodular adrenal hyperplasia (idiopathic hyperaldosteronism).
2 DOSAGE AND ADMINISTRATION
2.1 General Considerations
Spironolactone can be taken with or without food, but should be taken consistently with respect to food [see Clinical Pharmacology (12.3)].
2.2 Treatment of Heart Failure
In patients with serum potassium ≤5.0 mEq/L and eGFR >50 mL/min/1.73 m2 , initiate treatment at 25 mg once daily. Patients who tolerate 25 mg once daily may have their dosage increased to 50 mg once daily as clinically indicated. Patients who develop hyperkalemia on 25 mg once daily may have their dosage reduced to 25 mg every other day [see Warnings and Precautions (5.1)]. In patients with an eGFR between 30 and 50 mL/min/1.73 m2 , consider initiating therapy at 25 mg every other day because of the risk of hyperkalemia [see Use in Specific Populations (8.6)].
2.3 Treatment of Essential Hypertension
The recommended initial daily dose is 25 mg to 100 mg of spironolactone administered in either single or divided doses is recommended. Dosage can be titrated at two-week intervals. Doses greater than 100 mg/day generally do not provide additional reductions in blood pressure.
2.4 Treatment of Edema
In patients with cirrhosis, initiate therapy in a hospital setting and titrate slowly [see Use in Specific Populations (8.7)]. The recommended initial daily dosage is 100 mg of spironolactone administered in either single or divided doses, but may range from 25 mg to 200 mg daily. When given as the sole agent for diuresis, administer for at least five days before increasing dose to obtain desired effect.
2.5 Treatment of Primary Hyperaldosteronism
Administer spironolactone in doses of 100 mg to 400 mg daily in preparation for surgery. For patients who are considered unsuitable for surgery, spironolactone can be used as long-term maintenance therapy at the lowest effective dosage determined for the individual patient.
3 DOSAGE FORMS AND STRENGTHS
Tablets: 25 mg are white to off-white, round, biconvex, film-coated tablets debossed with ‘660’ on one side and plain on the other side.
Tablets: 50 mg are white to off-white, oval shaped, biconvex, film-coated tablets debossed with ‘661’ on the scored side and plain on the other side.
Tablets: 100 mg are white to off-white, round, biconvex, film-coated tablets debossed with ‘662’ on one side and scored on the other side.
Spironolactone tablets are contraindicated in the patients with:
- Addison’s disease
- Concomitant use of eplerenone
5 WARNINGS AND PRECAUTIONS
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. More frequent monitoring may be needed when spironolactone is given with other drugs that cause hyperkalemia or in patients with impaired renal function.
If hyperkalemia occurs, decrease the dose or discontinue spironolactone and treat hyperkalemia.
5.2 Hypotension and Worsening Renal Function
Excessive diuresis may cause symptomatic dehydration, hypotension and worsening renal function, particularly in salt-depleted patients or those taking angiotensin converting enzyme inhibitors and angiotensin II receptor blockers. Worsening of renal function can also occur with concomitant use of nephrotoxic drugs (e.g., aminoglycosides, cisplatin, and NSAIDs). Monitor volume status and renal function periodically.
5.3 Electrolyte and Metabolic Abnormalities
In addition to causing hyperkalemia, spironolactone can cause hyponatremia, hypomagnesemia, hypocalcemia, hypochloremic alkalosis, and hyperglycemia. Asymptomatic hyperuricemia can occur and rarely gout is precipitated. Monitor serum electrolytes, uric acid and blood glucose periodically.
Spironolactone can cause gynecomastia. In Randomized Spironolactone Evaluation Study, patients with heart failure treated with a mean dose of 26 mg of spironolactone once daily, about 9% of the male subjects developed gynecomastia. The risk of gynecomastia increases in a dose-dependent manner with an onset that varies widely from 1 to 2 months to over a year. Gynecomastia is usually reversible.
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