page108
impairment);
manufacturers advise avoid in severe
impairment
Pregnancy
not used to treat gestational hypertension
Breast-feeding
present in milk—manufacturer
advises avoid
Side-effects
include gastro-intestinal disturbances,
dry mouth,
rashes;
slight decrease in blood pressure,
hyperkalaemia,
hyponatraemia;
photosensitivity and
blood disorders also reported;
triamterene found in
kidney stones
Dose
. Initially 150–250 mg daily,
reducing to alternate days
after 1 week; taken in divided doses after breakfast
and lunch;
lower initial dose when given with other
diuretics
Counselling
Urine may look slightly blue in some lights
Dytac
c
(Goldshield) A
Capsules
,
maroon,
triamterene 50 mg,
net price 30-
cap pack = £17.35 Label:
14,
(see above),
21
Compound preparations with thiazides or loop
diuretics
Section 2.2.4
Aldosterone antagonists
Spironolactone potentiates thiazide or loop diuretics by
antagonising
aldosterone;
it
is
a
potassium-sparing
diuretic.
Spironolactone is of
value in the treatment of
oedema and ascites caused by cirrhosis of
the liver;
furosemide (section 2.2.2)
can be used as an adjunct.
Low doses of spironolactone are beneficial in moderate
to severe heart failure,
see section 2.5.5.
Spironolactone
is
also used in primary
hyperaldo-
steronism (Conn’s syndrome). It is given before surgery
or if surgery is not appropriate,
in the lowest effective
dose for maintenance.
Eplerenone is licensed for
use as an adjunct
in left
ventricular dysfunction with evidence of
heart
failure
after a myocardial infarction (see also section 2.5.5 and
section 2.10.1).
Potassium supplements must
not be given with aldo-
sterone antagonists.
EPLERENONE
Indications
adjunct in stable patients with left ventri-
cular dysfunction with evidence of heart failure,
fol-
lowing myocardial infarction (start therapy within 3–
14 days of event)
Cautions
measure plasma-potassium concentration
before treatment,
during initiation,
and when dose
changed; elderly; interactions: Appendix 1 (diuretics)
Contra-indications
hyperkalaemia;
concomitant use
of potassium-sparing diuretics or potassium supple-
ments
Hepatic impairment
avoid in severe liver disease
Renal impairment
increased risk of hyperkalaemia—
close monitoring required;
avoid if eGFR less than
50 mL/minute/1.73 m
2
Pregnancy
manufacturer advises caution—no infor-
mation available
Breast-feeding
manufacturer advises use only if
potential benefit outweighs risk
Side-effects
diarrhoea,
nausea;
hypotension;
dizzi-
ness;
hyperkalaemia;
rash;
less commonly
flatulence,
vomiting,
atrial fibrillation,
postural hypotension,
arterial thrombosis,
dyslipidaemia,
pharyngitis,
head-
ache,
insomnia,
gynaecomastia,
pyelonephritis,
hyponatraemia,
dehydration,
eosinophilia,
asthenia,
malaise,
back pain,
leg cramps,
impaired renal func-
tion,
azotaemia,
sweating and pruritus
Dose
. Initially 25 mg once daily, increased within 4 weeks to
50 mg once daily;
CHILD
not recommended
Inspra
c
(Pfizer) T A
Tablets
,
yellow,
f/c,
eplerenone 25 mg,
net price 28-
tab pack = £42.72;
50 mg,
28-tab pack = £42.72
SPIRONOLACTONE
Indications
oedema and ascites in cirrhosis of the
liver,
malignant ascites,
nephrotic syndrome,
conges-
tive heart failure (section 2.5.5);
primary hyperaldo-
steronism
Cautions
potential metabolic products carcinogenic in
rodents
;
elderly; monitor electrolytes (discontinue if
hyperkalaemia);
acute porphyria (section 9.8.2);
interactions: Appendix 1 (diuretics)
Contra-indications
hyperkalaemia,
hyponatraemia;
anuria;
Addison’s disease
Renal impairment
monitor plasma-potassium con-
centration (high risk of hyperkalaemia in renal
impairment);
avoid if rapidly deteriorating or severe
impairment
Pregnancy
feminisation of male fetus in
animal
stu-
dies
Breast-feeding
metabolites present in milk,
but
amount probably too small to be harmful
Side-effects
gastro-intestinal disturbances,
hepato-
toxicity; malaise,
headache,
confusion,
drowsiness,
dizziness;
gynaecomastia,
benign breast tumour,
breast pain, menstrual disturbances, changes in libido;
hypertrichosis,
hyperkalaemia (discontinue),
hypo-
natraemia,
acute renal failure,
hyperuricaemia,
leucopenia,
agranulocytosis,
thrombocytopenia;
leg
cramps;
alopecia,
hirsutism,
rash,
and Stevens-John-
son syndrome
Dose
. 100–200 mg daily,
increased to 400 mg if required;
CHILD
under 18 years,
see
BNF for Children
. Heart failure,
see section 2.5.5
Spironolactone
(Non-proprietary) A
Tablets
,
spironolactone 25 mg,
net price 28 = £1.50;
50 mg,
28 = £2.11;
100 mg,
28 = £2.46.
Label:
21
Oral suspensions
,
spironolactone 5 mg/5 mL,
10 mg/5 mL, 25 mg/5 mL, 50 mg/5 mL, and 100 mg/
5 mL.
Label:
21
Available from ‘special-order’
manufacturers or specialist
importing companies, see p.
988
Aldactone
c
(Pharmacia) A
Tablets
,
f/c,
spironolactone 25 mg (buff),
net price
100-tab pack = £8.89;
50 mg (white),
100-tab pack =
£17.78;
100 mg (buff),
28-tab pack = £9.96.
Label:
21
With thiazides or loop diuretics
Section 2.2.4
88
2.2.3 Potassium-sparing diuretics and aldosterone antagonists
BNF 61
2
Cardiovascular system