Spironolactone gynaecomastia

The aim is to remove the fluid gradually with a maximum weight loss of 0.5 kg/day in the absence of peripheral oedema, or 1.0 kg/day if peripheral oedema is present. Too rapid a diuresis will result in intravascular fluid loss rather than the peripheral oedema. The diuretic should be stopped if the serum sodium falls below 120 mmol/L or if there is a rising serum creatinine. Urinary electrolytes should be monitored to ensure that the spironolactone therapy is effective. The aim is to reverse the sodium/potassium ratio in the urine so that more sodium than potassium is excreted. Most frequent side-effects of spironolactone are those related to its anti-androgenic activity, such as decreased libido, impotence and gynaecomastia in men and menstrual irregularities in women. Other side-effects include hyperkalaemia, uraemia, hyponatraemia and nausea. 

Gynaecomastia, unless related to spironolactone use, indicates that the liver s metabolising capacity is reduced as it is unable to metabolise oestrogens. 

OESTROGENS 1. ANTICANCER AND IMMUNOMODULATING DRUGS - cidosporin, tacrolimus 2. CALCIUM CHANNEL BLOCKERS-nicardipine, nisoldipine, verapamil 3. DIURETICS-spironolactone Risk of gynaecomastia Inhibition of 2-hydroxylation or 17-oxidation of oestradiol in the liver, causing T oestradiol pool in the body Watch for gynaecomastia and warn patients... 

The RALES trial randomised 1663 patients with stable heart failure to either placebo or spironolactone (New England Journal of Medicine 1999 341 709). All patients were maintained on their optimised therapy that included ACE inhibitors. After 2 years of follow-up the trial was terminated prematurely due to a 30% reduction of mortality in the spironolactone treated patients both progressive pump failure and sudden death were significanly reduced. Gynaecomastia or breast discomfort occurred in 10% of treated patients (1% in controls), but significant h) erkalemia occurred in surprisingly few patients. RALES was not adequately powered to decide whether the action of spironolactone is additive to that of a p-blocker. 

The dosage of spironolactone is 100 to 400 mg/day in 2-3 single doses. That of potassium canrenoate amounts 100 to 800 mg/day. When therapy commences with potassium canrenoate, spironolactone should be administered orally 1-2 days prior to the intended termination of the i.v. application to ensure a smooth transition, since the onset of its effect is delayed. In 25-30% of male patients, long-term application leads to (generally reversible) potency disorders and gynaecomastia. 

A single case report describes the development of gynaecomastia and a rash when a man taking spironolactone was given dextropropoxyphene. 

Hyperkalemia, renal insufficiency, gynaecomastia (spironolactone use), symptomatic hypotension, miscellaneous (nausea, headache, diarrhoea)... 

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