In the Journals

High-dose spironolactone shows benefit in patients with acute HF resistant to loop diuretics

In a small pilot study, high-dose spironolactone was safe and effective in patients with acute decompensated HF who were resistant to loop diuretics.

Shweta Bansal, MD, nephrologist at the University of Texas Health at San Antonio and South Texas Veterans Health Care System in San Antonio, and colleagues analyzed data from 47 patients who were recently hospitalized for HF and had at least one sign and one symptom of hypervolemia. Patients were weighed daily and were asked about their dyspnea level.

Patients were categorized by response to loop diuretics (n = 27; median age, 54 years; 78% men) or resistance to loop diuretics (n = 20; median age, 62 years; 60% men). Those who lost less than 0.5 kg per day despite receiving furosemide and those who lost less than 0.5 kg per day 48 hours after admission regardless of diuretic dose were given 100 mg spironolactone per day. Patients who were already receiving 25 mg spironolactone per day were given 100 mg per day, and the next day the dose was increased to 200 mg per day if weight loss was less than 0.5 mg per day and creatinine increase was less than 26.52 µmol/L.

Of the patients who were resistant to loop diuretics and received high-dose spironolactone, one patient withdrew from the study due to mechanical ventilation. Fourteen patients reported improvements in dyspnea by day 4 after high-dose spironolactone therapy was initiated. There were no reports of patients with a potassium level above 5.5 mmol/L.

Two patients had substantial weight loss during a 4-day period, which contributed to increases in creatinine levels of 35.36 µmol/L. Creatinine level returned to baseline at a follow-up visit for one patient, and the other patient later developed cardiac arrest and died.

In a small pilot study, high-dose spironolactone was safe and effective in patients with acute decompensated HF who were resistant to loop diuretics.
Source: Adobe Stock

The researchers noted that these findings differ from the data reported in the ATHENA-HF trial, in which spironolactone 100 mg did not result in improved congestion or N-terminal pro-B-type natriuretic peptide. In this pilot study, the researchers evaluated a higher dose of spironolactone than in ATHENA-HF.

“When interpreting our results, readers should keep in mind that our study was small, it did not include a traditional control group and we did not measure readmission rates,” Bansal and colleagues wrote. “Nevertheless, we believe that our findings and those of other trials with similar designs indicate that it is time to conduct a randomized controlled trial to examine whether high-dose aldosterone antagonists have a role in managing patients with acute decompensated heart failure who are resistant to loop diuretics.” – by Darlene Dobkowski

Disclosures: Bansal reports she received grants from Relypsa. Please see the study for all other authors’ relevant financial disclosures.

In a small pilot study, high-dose spironolactone was safe and effective in patients with acute decompensated HF who were resistant to loop diuretics.

Shweta Bansal, MD, nephrologist at the University of Texas Health at San Antonio and South Texas Veterans Health Care System in San Antonio, and colleagues analyzed data from 47 patients who were recently hospitalized for HF and had at least one sign and one symptom of hypervolemia. Patients were weighed daily and were asked about their dyspnea level.

Patients were categorized by response to loop diuretics (n = 27; median age, 54 years; 78% men) or resistance to loop diuretics (n = 20; median age, 62 years; 60% men). Those who lost less than 0.5 kg per day despite receiving furosemide and those who lost less than 0.5 kg per day 48 hours after admission regardless of diuretic dose were given 100 mg spironolactone per day. Patients who were already receiving 25 mg spironolactone per day were given 100 mg per day, and the next day the dose was increased to 200 mg per day if weight loss was less than 0.5 mg per day and creatinine increase was less than 26.52 µmol/L.

Of the patients who were resistant to loop diuretics and received high-dose spironolactone, one patient withdrew from the study due to mechanical ventilation. Fourteen patients reported improvements in dyspnea by day 4 after high-dose spironolactone therapy was initiated. There were no reports of patients with a potassium level above 5.5 mmol/L.

Two patients had substantial weight loss during a 4-day period, which contributed to increases in creatinine levels of 35.36 µmol/L. Creatinine level returned to baseline at a follow-up visit for one patient, and the other patient later developed cardiac arrest and died.

In a small pilot study, high-dose spironolactone was safe and effective in patients with acute decompensated HF who were resistant to loop diuretics.
Source: Adobe Stock

The researchers noted that these findings differ from the data reported in the ATHENA-HF trial, in which spironolactone 100 mg did not result in improved congestion or N-terminal pro-B-type natriuretic peptide. In this pilot study, the researchers evaluated a higher dose of spironolactone than in ATHENA-HF.

“When interpreting our results, readers should keep in mind that our study was small, it did not include a traditional control group and we did not measure readmission rates,” Bansal and colleagues wrote. “Nevertheless, we believe that our findings and those of other trials with similar designs indicate that it is time to conduct a randomized controlled trial to examine whether high-dose aldosterone antagonists have a role in managing patients with acute decompensated heart failure who are resistant to loop diuretics.” – by Darlene Dobkowski

Disclosures: Bansal reports she received grants from Relypsa. Please see the study for all other authors’ relevant financial disclosures.