Spironolactone hyperkalemia with

In patients with renal insufficiency there is an increased risk of hyperkalemia with spironolactone serum potassium should be monitored regularly. 

A. The toxicity of these drugs is associated with their pharmacologic effects, which decrease fluid volume and promote electrolyte loss, including dehydration, hypokalemia (or hyperkalemia, with spironolactone), hypomagnesemia, hyponatremia, and hypochloremic alkalosis. Electrolyte imbalance may lead to cardiac arrhythmias and may enhance digitalis toxicity (see p 155). Diuret-... 

Hyperkalemia Carefully evaluate patients for possible fluid and electrolyte balance disturbances. Hyperkalemia may occur with impaired renal function or excessive potassium intake and can cause cardiac irregularities that may be fatal. Ordinarily, do not give potassium supplements with spironolactone. 

Spironolactone should not be used concurrently with another potassiumsparing agent (e.g., amiloride, triamterene), or potassium-containing medications, or potassium supplements, or salt substitutes containing substantial amounts of potassium. Concomitant therapy with these drugs may increase the risk of hyperkalemia compared with spironolactone alone [65, 84]. 

The risk of hyperkalemia with potassium chloride formulations increases when they are given in combination with drugs that are potassium sparing (8), such as ACE inhibitors and angiotensin II receptor antagonists (9), canrenone, spironolactone (10), amiloride, and triamterene (11). 

Colestyramine in combination with spironolactone has been reported to cause severe hyperkalemia (25), presumably because it causes exchange of chloride for... 

The AASLD practice guidelines recommend that diuretic therapy be initiated with the combination of spironolactone and furosemide. Spironolactone alone was commonly recommended for initial therapy, but clinical trials have demonstrated a 14-day delay in the onset of action, as well as the development hyperkalemia when spironolactone is used alone. Administering spironolactone in single daily doses is justified based on its pharmacokinetics and helps to improve patient compliance. If tense ascites is present, paracentesis... 

Patients with cirrhosis should initially be treated with spironolactone in the absence of impaired glomerular filtration rate and hyperkalemia. Thiazides may then be added for patients with a creatinine clearance >50 mL/min. For those patients who remain diuretic resistant, a loop diuretic may replace the thiazide. 

Secondary hyperaldosteronism plays a major role in the pathogenesis of edema in patients with cirrhosis. Therefore these patients should initially be treated with spironolactone in the absence of impaired GFR and hyperkalemia. Thiazides may then be added for patients with a creatinine clearance >50 mL/min. For those patients who remain diuretic resistant, a loop diuretic may replace the thiazide. Patients with impaired GFR (creatinine clearance of <30 mL/min) generally will require a loop diuretic, with addition of a thiazide in those who do not achieve adequate diuresis. Care should be taken to avoid hypokalemia, which may precipitate hepatic encephalopathy by increasing ammoniagenesis (Fig. 49-8). ... 

PO. Excreted unchanged in kidney, 6 hr half-life. Can be used in patients with hepatic insufficiency. Severe hyperkalemia with potassium supplements. Increased hyperkalemia with other K+-sparing diuretics. More rapid onset than spironolactone. 

Electrolyte balance In a retrospective study of 2538 patients with newly diagnosed systolic HF, total of 521 patients who were started on spironolactone showed higher rates of severe hyperkalemia (4.8 vs 1.6 per 100 person-years, p < 0.001) compared with spironolactone nonuse patients. Overall, severe hyperkalemia occurred in 6.0% patients... 

Hyperkalemia (increase in potassium in the blood), a serious event, may be seen with the administration of potassium-sparing diuretics. Hyperkalemia is most likely to occur in patients with an inadequate fluid intake and urine output, those with diabetes or renal disease tiie elderly, and those who are severely ill. In patients taking spironolactone, gynecomastia (breast enlargement in tiie male) may occur. This reaction appears to be related to both dosage and duration of therapy. The gynecomastia is usually reversible when therapy is discontinued, but in rare instances, some breast enlargement may remain. 

Potassium-sparing diuretics may cause hyperkalemia, especially in patients with chronic kidney disease or diabetes, and in patients receiving concurrent treatment with an ACE inhibitor, ARB, NSAID, or potassium supplement. Eplerenone has an increased risk for hyperkalemia and is contraindicated in patients with impaired renal function or type 2 diabetes with proteinuria. Spironolactone may cause gynecomastia in up to 10% of patients, but this effect occurs rarely with eplerenone. 

Hyperkalemia Yasmin contains the progestin drospirenone that has antimineralocorticoid activity, including the potential for hyperkalemia in high-risk patients, comparable to a 25 mg dose of spironolactone. Yasmin should not be used in patients with conditions that predispose to hyperkalemia. Women receiving daily, long-term treatment for chronic conditions or diseases with medications that may increase serum potassium should have their serum potassium level checked during the first treatment cycle. 

A small increase (mean increase of 0.1 mEq/L) was observed in patients treated with candesartan alone but was rarely of clinical importance. One patient from a CHF trial was withdrawn for hyperkalemia (serum potassium, 7.5 mEq/L). This patient was also receiving spironolactone. 

Patients receiving spironolactone or amiloride anuria severe hepatic disease hyperkalemia hypersensitivity to triamterene severe or progressive kidney disease or dysfunction, with the possible exception of nephrosis preexisting elevated serum potassium (impaired renal function, azotemia) or patients who develop hyperkalemia while on triamterene. 

In patients with renal insufficiency, spironolactone may induce hyperkalemia. 

Adverse effects Renal function may deteriorate with the decreased circulating fluid volume, especially after the addition of another diuretic drug acting on the RAAS system, and careful monitoring of serum creatinine is essential. Serum potassium should be monitored within one week of initiation and at least every four weeks for the first three months and every three months thereafter. It should also be monitored at any dose change in spironolactone or if there is a change in concomitant medications that affects the potassium balance. The spironolactone dose (standard 25 mg per day) should be reduced if potassium levels are <5.4 mEq/L, and treatment should be discontinued if painful gynecomastia or serious renal dysfunction or hyperkalemia result. 

Because indomethacin may increase serum potassium concentrations, indomethacin and spironolactone should be administered concomitantly with caution. Potassium-sparing diuretics should be used with caution, and serum potassium should be determined frequently in patients receiving an angiotensin-converting enzyme (ACE) inhibitor (e.g., captopril). Concomitant administration with an ACE inhibitor may increase the risk of hyperkalemia. The dosage of spironolactone should be reduced, or the drug discontinued, as necessary. Patients with renal impairment may be at increased risk of hyperkalemia [65]. 

Hyperkalemia May occur in up to 26% of patients receiving spironolactone, even when combined with thiazide diuretics. Irregular heartbeat is usually the earliest clinical indication of hyperkalemia, and is readily detected by ECG. Other signs and symptoms include confusion, nervousness, numbness or tingling in extremities (hands, feet, or lips), shortness of breath or difficult breathing, unusual tiredness or weakness, or weakness or heaviness of legs. 

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