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Spironolactone, sold under the brand name Aldactone among others, is a medication that is primarily used to treat fluid build-up due to heart failure, liver scarring, or kidney disease.
Common side effects include electrolyte abnormalities, particularly high blood potassium, nausea, vomiting, headache, rashes, and a decreased desire for sex.
Spironolactone was discovered in 1957 and was introduced in 1959.
Contents
1 Medical uses
1.1 Heart failure
1.2 High blood pressure
1.3 Skin and hair conditions
1.4 Transgender hormone therapy
1.5 Doses and forms
1.6 Comparison
2 Contraindications
3 Side effects
3.1 High potassium levels
3.2 Breast changes
3.3 Menstrual disturbances
3.4 Rare reactions
3.5 Spironolactone bodies
3.6 Pregnancy and breastfeeding
4 Overdose
5 Interactions
6 Pharmacology
6.1 Pharmacodynamics
6.2 Pharmacokinetics
6.2.1 Absorption
6.2.2 Distribution
6.2.3 Metabolism
6.2.4 Elimination
7 Chemistry
7.1 Names
7.2 Analogues
7.3 Synthesis
8 History
9 Society and culture
9.1 Generic names
9.2 Brand names
9.3 Availability
10 Research
10.1 Enlarged prostate
10.2 Epstein–Barr virus
10.3 Other conditions
11 References
12 External links
Medical uses
Spironolactone is used primarily to treat heart failure, edematous conditions such as nephrotic syndrome or ascites in people with liver disease, essential hypertension, low blood levels of potassium, secondary hyperaldosteronism (such as occurs with liver cirrhosis ), and Conn’s syndrome (primary hyperaldosteronism). The most common use of spironolactone is in the treatment of heart failure.
Spironolactone has antiandrogenic activity. For this reason, it is frequently used to treat a variety of dermatological conditions in which androgens play a role. Some of these uses include acne, seborrhea, hirsutism, and pattern hair loss in women.
Heart failure
While loop diuretics remain first-line for most people with heart failure, spironolactone has shown to reduce both morbidity and mortality in numerous studies and remains an important agent for treating fluid retention, edema, and symptoms of heart failure. Current recommendations from the American Heart Association are to use spironolactone in patients with NYHA Class II-IV heart failure who have a left ventricular ejection fraction of less than 35%.
In a randomized evaluation which studied people with severe congestive heart failure, people treated with spironolactone were found to have a relative risk of death of 0.70 or an overall 30% relative risk reduction compared to the placebo group, indicating a significant death and morbidity benefit of the medication. People in the study’s intervention arm also had fewer symptoms of heart failure and were hospitalized less frequently.
It is recommended that alternatives to spironolactone be considered if serum creatinine is greater than 2.5 mg/dL (221 µmol/L) in males or greater than 2 mg/dL (176.8 µmol/L) in females, if glomerular filtration rate is below 30 mL/min or with a serum potassium of greater than 5.0 mEq/L given the potential for adverse events detailed elsewhere in this article. Doses should be adjusted according to the degree of kidney function as well.
According to systematic review, in heart failure with preserved ejection fraction, treatment with spironolactone did not improve patient outcomes. This is based on the TOPCAT Trial examining this issue, which found that of those treated with placebo had a 20.4% incidence of negative outcome vs 18.6% incidence of negative outcome with spironolactone. However, because the p-value of the study was 0.14, and the unadjusted hazard ratio was 0.89 with a 95% confidence interval of 0.77 to 1.04, it is determined the finding had no statistical significance. Hence the finding that patient outcomes are not improved with use of spironolactone.
Due to its antiandrogenic properties, spironolactone can cause effects associated with low androgen levels and hypogonadism in males. For this reason, men are typically not prescribed spironolactone for any longer than a short period of time, e.g., for an acute exacerbation of heart failure. A newer medication, eplerenone, has been approved by the U.S. Food and Drug Administration for the treatment of heart failure, and lacks the antiandrogenic effects of spironolactone. As such, it is far more suitable for men for whom long-term medication is being chosen. However, eplerenone may not be as effective as spironolactone or the related medication canrenone in reducing mortality from heart failure.
The clinical benefits of spironolactone as a diuretic are typically not seen until 2 to 3 days after dosing begins. Likewise, the maximal antihypertensive effect may not be seen for 2 to 3 weeks.
Unlike with some other diuretics, potassium supplementation should not be administered while taking spironolactone, as this may cause dangerous elevations in serum potassium levels resulting in hyperkalemia and potentially deadly abnormal heart rhythms.
High blood pressure
About 1 in 100 people with hypertension has elevated levels of aldosterone; in these people, the antihypertensive effect of spironolactone may exceed that of complex combined regimens of other antihypertensives since it targets the primary cause of the elevated blood pressure. However, a Cochrane review found adverse effects at high doses and little effect on blood pressure at low doses in the majority of people with high blood pressure.
Skin and hair conditions
Androgens like testosterone and DHT play a critical role in the pathogenesis of a number of dermatological conditions including acne, seborrhea, hirsutism (excessive facial/body hair growth in women), and pattern hair loss (androgenic alopecia).
Because of the antiandrogenic activity of spironolactone, it can be quite effective in treating acne in women,
Antiandrogens like spironolactone are male-specific teratogens which can feminize male fetuses due to their antiandrogenic effects.
Spironolactone is not generally used in men for the treatment of androgen-dependent dermatological conditions because of its feminizing side effects, but it is effective for such indications in men similarly.
Transgender hormone therapy
Spironolactone is frequently used as a component of feminizing hormone therapy in transgender women, especially in the United States (where cyproterone acetate is not available), usually in addition to an estrogen.
Doses and forms
Spironolactone is typically used at a low dosage of 25 to 50 mg/day in the treatment of heart failure,
Spironolactone is available in the form of tablets (25 mg, 50 mg, 100 mg; brand name Aldactone, others) and suspensions (25 mg/5 mL; brand name CaroSpir) for use by mouth.
Comparison
There are few available options for antiandrogen therapy. Spironolactone, cyproterone acetate, and flutamide are some of the most well-known and widely used medications.
Flutamide, another frequently used antiandrogen which is nonsteroidal and a pure androgen blocker, though much less potent by weight and binding affinity to the androgen receptor than either spironolactone or cyproterone acetate, As such, spironolactone may be the only practical, safe, available, and well-supported antiandrogen option in some cases.
In a study of the predictive markers for transgender women requesting breast augmentation, there was a significantly higher rate of those treated with spironolactone requesting breast augmentation compared to other antiandrogens such as cyproterone acetate or GnRH analogues, which was interpreted by the study authors as being potentially indicative that spironolactone may result in poorer breast development in comparison.
Contraindications
Contraindications of spironolactone include hyperkalemia (high potassium levels), severe and end-stage kidney disease (due to high hyperkalemia risk, except possibly in those on dialysis ), Addison’s disease (adrenal insufficiency and low aldosterone levels), and concomitant use of eplerenone.
Side effects
The most common side effect of spironolactone is urinary frequency. Other general side effects include dehydration, hyponatremia (low sodium levels), mild hypotension (low blood pressure ),
The most important potential side effect of spironolactone is hyperkalemia (high potassium levels), which, in severe cases, can be life-threatening. Hyperkalemia in these people can present as a non anion-gap metabolic acidosis. Spironolactone may put people at a heightened risk for gastrointestinal issues like nausea, vomiting, diarrhea, cramping, and gastritis. In addition, there has been some evidence suggesting an association between use of the medication and bleeding from the stomach and duodenum, though a causal relationship between the two has not been established.
Increased glucocorticoid activity in the body is associated with depression.
High potassium levels
Spironolactone can cause hyperkalemia, or high blood potassium levels.
Although spironolactone poses an important risk of hyperkalemia in the elderly, in those with kidney or cardiovascular disease, and/or in those taking medications or supplements which increase circulating potassium levels, a large retrospective study found that the rate of hyperkalemia in young women without such characteristics who had been treated with high doses of spironolactone for dermatological conditions did not differ from that of controls.
Breast changes
Spironolactone frequently causes breast pain and breast enlargement in women.
Spironolactone also commonly and dose-dependently produces gynecomastia (breast development) as a side effect in men.
The time to onset of spironolactone-induced gynecomastia has been found to be 27 ± 20 months at low doses and 9 ± 12 months at high doses.
Menstrual disturbances
In women, menstrual disturbances are common during spironolactone treatment, with 10 to 50% of women experiencing them at moderate doses and almost all experiencing them at a high doses.
Rare reactions
Aside from hyperkalemia, spironolactone may rarely cause severe side effects such as anaphylaxis, kidney failure, hepatitis (two reported cases, neither serious),
Spironolactone bodies
Micrograph ( H&E stain ) of an adrenal gland showing spironolactone bodies.
Long-term administration of spironolactone gives the histologic characteristic of “spironolactone bodies” in the adrenal cortex. Spironolactone bodies are eosinophilic, round, concentrically laminated cytoplasmic inclusions surrounded by clear halos in preparations stained with hematoxylin and eosin.
Pregnancy and breastfeeding
Spironolactone is considered Pregnancy Category C meaning that it is unclear if it is safe for use during pregnancy.
A study found that spironolactone was not associated with teratogenicity in the offspring of rats.
In practice however, although experience is limited, spironolactone has never been reported to cause observable feminization or any other congenital defects in humans.
Overdose
Spironolactone is relatively safe in acute overdose.
There is no specific antidote for overdose of spironolactone.
Interactions
Spironolactone often increases serum potassium levels and can cause hyperkalemia, a very serious condition. Therefore, it is recommended that people using this medication avoid potassium supplements and salt substitutes containing potassium.
Spironolactone has been reported to induce the enzymes CYP3A4 and certain UDP-glucuronosyltransferases (UGTs), which can result in interactions with various medications.
Licorice, which has indirect mineralocorticoid activity by inhibiting mineralocorticoid metabolism, has been found to inhibit the antimineralocorticoid effects of spironolactone.
Some research has suggested that spironolactone might be able to interfere with the effectiveness of antidepressant treatment. As the medication acts as an antimineralocorticoid, it is thought that it might be able to reduce the effectiveness of certain antidepressants by interfering with normalization of the hypothalamic–pituitary–adrenal axis and by increasing levels of glucocorticoids such as cortisol.
Pharmacology
Pharmacodynamics
Main article: Pharmacodynamics of spironolactone
7α-Thiomethylspironolactone, the major active form of spironolactone. It accounts for about 80% of the potassium-sparing effect of spironolactone.
Canrenone, the second major active form of spironolactone. It accounts for around 10 to 25% of the potassium-sparing effect of spironolactone.
The pharmacodynamics of spironolactone are characterized by high antimineralocorticoid activity, moderate antiandrogenic activity, and weak steroidogenesis inhibition, among other more minor activities.
Spironolactone is a potent antimineralocorticoid.
Spironolactone is a moderate antiandrogen.
Spironolactone is a weak steroidogenesis inhibitor.
Spironolactone has been found in some studies to increase levels of estradiol, an estrogen, although many other studies have found no changes in estradiol levels.
In response to the antimineralocorticoid activity spironolactone, and in an attempt to maintain homeostasis, the body increases aldosterone production in the adrenal cortex.
Other activities of spironolactone may include very weak interactions with the estrogen and progesterone receptors and agonism of the pregnane X receptor.
Pharmacokinetics
The pharmacokinetics of spironolactone have not been studied well, which is in part because it is an old medication that was developed in the 1950s.
Absorption
Levels of spironolactone and its major active metabolites after a single oral dose of 100 mg spironolactone in humans.
The bioavailability of spironolactone when taken by mouth is 60 to 90%.
Little or no systemic absorption has been observed with topical spironolactone.
Distribution
Spironolactone and its metabolite canrenone are highly plasma protein bound, with percentages of 88.0% and 99.2%, respectively.
Metabolism
Spironolactone metabolism in humans.
Spironolactone is rapidly and extensively metabolized in the liver upon oral administration and has a very short terminal half-life of 1.4 hours.
Spironolactone is hydrolyzed or deacetylated at the thioester of the C7α position into 7α-TS by carboxylesterases.
Pharmacokinetics of 100 mg/day spironolactone and its metabolites
Compound
C max (day 1)
C max (day 15)
AUC (day 15)
t 1/2
Spironolactone
72 ng/mL (173 nmol/L)
80 ng/mL (192 nmol/L)
231 ng•hour/mL (555 nmol•hour/L)
1.4 hours
Canrenone
155 ng/mL (455 nmol/L)
181 ng/mL (532 nmol/L)
2,173 ng•hour/mL (6,382 nmol•hour/L)
16.5 hours
7α-TMS
359 ng/mL (924 nmol/L)
391 ng/mL (1,006 nmol/L)
2,804 ng•hour/mL (7,216 nmol•hour/L)
13.8 hours
6β-OH-7α-TMS
101 ng/mL (250 nmol/L)
125 ng/mL (309 nmol/L)
1,727 ng•hour/mL (4,269 nmol•hour/L)
15.0 hours
Elimination
The majority of spironolactone is eliminated by the kidneys, while minimal amounts are handled by biliary excretion.
Chemistry
See also: Spirolactone and List of steroidal antiandrogens § Spirolactone derivatives
Spironolactone, also known as 7α-acetylthiospirolactone, is a steroidal 17α-spirolactone, or more simply a spirolactone.
Names
Spironolactone is also known by the following equivalent chemical names:
7α-Acetylthio-17α-hydroxy-3-oxopregn-4-ene-21-carboxylic acid γ-lactone
7α-Acetylthio-3-oxo-17α-pregn-4-ene-21,17β-carbolactone
3-(3-Oxo-7α-acetylthio-17β-hydroxyandrost-4-en-17α-yl)propionic acid lactone
7α-Acetylthio-17α-(2-carboxyethyl)androst-4-en-17β-ol-3-one γ-lactone
7α-Acetylthio-17α-(2-carboxyethyl)testosterone γ-lactone
Analogues
v t e Chemical structures of spirolactones
Progesterone
Spirolactone
Canrenone
Spironolactone
Drospirenone
Spirorenone
Chemical structures of progesterone and spirolactones (steroid-17α-spirolactones).
Spironolactone is closely related structurally to other clinically used spirolactones such as canrenone, potassium canrenoate, drospirenone, and eplerenone, as well as to the never-marketed spirolactones SC-5233 (6,7-dihydrocanrenone; 7α-desthioacetylspironolactone), SC-8109 (19-nor-6,7-dihydrocanrenone), spiroxasone, prorenone (SC-23133), mexrenone (SC-25152, ZK-32055), dicirenone (SC-26304), spirorenone (ZK-35973), and mespirenone (ZK-94679).
Synthesis
Chemical syntheses of spironolactone and its analogues and derivatives have been described and reviewed.
History
The natriuretic effects of progesterone were demonstrated in 1955, and the development of spironolactone as a synthetic antimineralocorticoid analogue of progesterone shortly followed this.
Society and culture
Generic names
The English, French, and generic name of the medication is spironolactone and this is its INN, USAN, USP, BAN, DCF, and JAN.
Spironolactone is also known by its developmental code names SC-9420 and NSC-150339.
Brand names
Spironolactone is marketed under a large number of brand names throughout the world.
Spironolactone is also formulated in combination with a variety of other medications, including with hydrochlorothiazide as Aldactazide, with hydroflumethiazide as Aldactide, Lasilacton, Lasilactone, and Spiromide, with altizide as Aldactacine and Aldactazine, with furosemide as Fruselac, with benazepril as Cardalis (veterinary), with metolazone as Metolactone, with bendroflumethiazide as Sali-Aldopur, and with torasemide as Dytor Plus, Torlactone, and Zator Plus.
Availability
Spironolactone is marketed widely throughout the world and is available in almost every country, including in the United States, Canada, the United Kingdom, other European countries, Australia, New Zealand, South Africa, Central and South America, and East and Southeast Asia.
Research
Enlarged prostate
Spironolactone has been studied at a high dosage in the treatment of benign prostatic hyperplasia (BPH; enlarged prostate).
Epstein–Barr virus
Spironolactone has been found to block Epstein–Barr virus (EBV) production and that of other human herpesviruses by inhibiting the function of an EBV protein SM, which is essential for infectious virus production.
Other conditions
Spironolactone has been studied in fibromyalgia in women.

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