Spironolactone

Spironolactone is primarily used in the treatment of heart failure with reduced ejection fraction (HFrEF), where it has demonstrated significant benefits in reducing mortality and hospitalizations when added to standard therapy. Multiple studies show that spironolactone improves left ventricular diastolic function and reduces heart failure hospitalisations in patients with heart failure with preserved ejection fraction (HFpEF), though without benefits in all-cause death or overall hospitalisation rates. Also, some evidence suggests spironolactone may be effective in HFpEF with resistant hypertension (defined as blood pressure >130/80 mmHg) refractory to an ACE inhibitor/ARB, calcium channel blocker, and diuretic. It is also used to treat 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 is also used to treat Bartter's syndrome due to its ability to raise potassium levels. Spironolactone, which has antiandrogenic effects, may help improve acne in adult women, with modest benefits demonstrated in recent clinical trials. Its use is limited by short-term outcome data and minimal reporting of side effects. It is considered a possible alternative to antibiotics for hormonal acne. It is also used to manage other androgen-related conditions such as hirsutism, seborrhoea, and female pattern hair loss Spironolactone is used for the treatment of hirsutism in the United States. High doses of spironolactone, which are needed for considerable antiandrogenic effects, are not recommended for men due to the high risk of feminization and other side effects. Spironolactone can be used to treat symptoms of hyperandrogenism, such as due to polycystic ovary syndrome. Heart failure Although loop diuretics help to treat acute symptoms of heart failure, mineralocorticoid receptor antagonist diuretics (such as spironolactone) can be used long-term to reduce mortality and morbidity associated with certain types of chronic heart failure. One randomized control trial in 1999 found that the addition of spironolactone to standard therapy reduced all-cause mortality in patients with HF by 30%. Spironolactone improves left ventricular diastolic function in patients with heart failure with preserved ejection fraction, but it has no effect on mortality and hospitalization. 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 US Food and Drug Administration (FDA) 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. While mineralocorticoid receptor antagonist (MRA) as a class (including spironolactone, eplerenone, and canrenone) is likely to be beneficial in heart-failure patients, the precise comparative magnitude of effect on mortality between spironolactone and eplerenone remains subject to some clinical uncertainty, with limited comparative data available for canrenone. High blood pressure About one in 100 people with hypertension have 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. There is no evidence of person-oriented outcome at any dose in this group. Antimineralocorticoids including spironolactone and eplerenone are first-line treatments for hyperaldosteronism. Skin and hair conditions Androgens such as testosterone and DHT play a critical role in the pathogenesis of a number of dermatological conditions including oily skin, acne, seborrhea, hirsutism (excessive facial/body hair growth in women), and male pattern hair loss (androgenic alopecia). In demonstration of this, women with complete androgen insensitivity syndrome do not produce sebum or develop acne and have little to no body, pubic, or axillary hair. Moreover, men with congenital 5α-reductase type II deficiency, 5α-reductase being an enzyme that greatly potentiates the androgenic effects of testosterone in the skin, have little to no acne, scanty facial hair, reduced body hair, and reportedly no incidence of male-pattern hair loss. Conversely, hyperandrogenism in women, for instance due to polycystic ovary syndrome or congenital adrenal hyperplasia, is commonly associated with acne and hirsutism, as well as virilization (masculinization) in general. In addition, spironolactone reduces oil that is naturally produced in the skin, so can be used to treat oily skin. There is tentative low quality evidence supporting its use for this indication. Antiandrogens such as spironolactone are male-specific teratogens, which can feminize male fetuses due to their antiandrogenic effects. For this reason, antiandrogens are recommended only to be used to treat women who are of reproductive age in conjunction with adequate contraception. 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. An additional example is the usefulness of spironolactone as an antiandrogen in transgender women and nonbinary individuals. Topical spironolactone is effective in the treatment of acne, as well. As a result, topical pharmaceutical formulations containing 2 or 5% spironolactone cream became available in Italy for the treatment of acne and hirsutism in the early 1990s. The products were discontinued in 2006 when the creams were added to the list of doping substances with a decree of the Ministry of Health that year. Some clinical research, though, has found that the effectiveness of spironolactone for hirsutism is greater than that of finasteride, but is less than that of flutamide. The combination of spironolactone with a birth-control pill in the treatment of acne appears to have similar effectiveness to a birth-control pill alone and the combination of a birth-control pill with cyproterone acetate, flutamide, or finasteride. However, the use of flutamide for acne is limited by its liver toxicity. Bicalutamide is a potential alternative to flutamide for acne as well. Spironolactone can be considered as a first-line treatment for acne in those who have failed other standard treatments such as topical therapies and under certain other circumstances, although this is controversial due to the side effects of spironolactone and its teratogenicity. Insufficient clinical evidence exists to compare the effectiveness of spironolactone with other antiandrogens for female-pattern hair loss. The effectiveness of spironolactone in the treatment of both acne and hirsutism appears to be dose-dependent, with higher doses being more effective than lower doses. Higher doses also have greater side effects, such as menstrual irregularities. It is the most commonly used antiandrogen in transfeminine people in the United States, whereas cyproterone acetate (CPA), which is not available in the United States, is widely used in Europe and throughout the rest of the world. However, spironolactone acts as a direct though weak androgen receptor antagonist rather than by suppressing testosterone levels, and hence its antiandrogenic effects and potential therapeutic benefits in this context are not necessarily reflected in testosterone levels. It had also been marketed in the form of 2 or 5% topical cream in Italy for the treatment of acne and hirsutism under the brand name Spiroderm, but this product is no longer available. The only antimineralocorticoid that is available as a solution for parenteral use is the related medication potassium canrenoate. ==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. It should also be used with caution in people with certain neurological disorders, as well as those who experience or have experienced anuria (lack of urine production), acute kidney injury, or significant impairment of kidney excretory function with risk of hyperkalemia. ==Side effects==

One of the most common side effects of spironolactone is frequent urination. Other general side effects include dehydration, hyponatremia (low sodium levels), mild hypotension, Aside from these adverse effects, the side effects of spironolactone in women taking high doses are minimal, and it is well tolerated. A potential side effect of spironolactone is hyperkalemia (high potassium levels), which in severe cases, can be life-threatening. Spironolactone may put people at a heightened risk for gastrointestinal issues such as nausea, vomiting, diarrhea, cramping, and gastritis. In addition, some evidence suggests an association between use of the medication and bleeding from the stomach and duodenum, Also, spironolactone is immunosuppressive in the treatment of sarcoidosis. Most of the side effects of spironolactone are dose-dependent. Rarely, this can be fatal. An abrupt and major increase in the rate of hospitalization due to hyperkalemia from 0.2 to 11% and in the rate of death due to hyperkalemia from 0.3 to 2.0 per 1,000 between early 1994 and late 2001 has been attributed to a parallel rise in the number of prescriptions written for spironolactone upon the publication of the Randomized Aldactone Evaluation Study (RALES) in July 1999. However, another population-based study in Scotland failed to replicate these findings. The risk of hyperkalemia with spironolactone is greatest in the elderly, in people with renal impairment (e.g., due to chronic kidney disease or diabetic nephropathy), in people taking certain other medications (including inhibitors, angiotensin II receptor blockers, nonsteroidal anti-inflammatory drugs, the antibiotic trimethoprim, and potassium supplements), and at higher dosages of spironolactone. 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 those of controls. This was the conclusion of a 2017 hybrid systematic review of studies of spironolactone for acne in women, as well, which found that hyperkalemia was rare and was invariably mild and clinically insignificant. A broader retrospective study found that the rate of hyperkalemia in gender-diverse individuals is correlated with age, with those above 45 years old being more at risk. The finding suggests that patients below or at 45 years old without other conditions that affect potassium handling can be spared from routine monitoring. Breast changes Spironolactone can cause breast pain and enlargement in women. Some women regard spironolactone-induced breast enlargement as a positive effect. At low doses, the rate is only 5 to 10%, The severity of gynecomastia with spironolactone varies considerably, but is usually mild. Menstrual disturbances Spironolactone at higher doses can cause menstrual irregularities as a side effect in women, The medication reportedly has no birth control effect. The weak progestogenic activity of spironolactone has been suggested to be responsible for these effects, although not established, and spironolactone has been shown to possess insignificant progestogenic and antiprogestogenic activity even at high dosages in women. An alternative proposed cause is inhibition of 17α-hydroxylase and hence sex steroid metabolism by spironolactone and consequent changes in sex hormone levels. Regardless of their mechanism, the menstrual disturbances associated with spironolactone can usually be controlled well by concomitant treatment with a birth-control pill, due to the progestin component. Mood changes Research is mixed on whether antimineralocorticoids such as spironolactone have positive or negative effects on mood. In any case, spironolactone might have the capacity to increase the risk of depressive symptoms. Lipid changes Spironolactone has been found to increase LDL ("bad") cholesterol and decrease HDL ("good") cholesterol levels at the relatively high doses used in women with polycystic ovary syndrome. As such, it may have unfavorable effects on the blood lipid profile in this context. Consequently, spironolactone probably should not be given to women with dyslipidemia (e.g., high cholesterol). and bicalutamide. hepatitis (two reported cases, neither serious), agranulocytosis, DRESS syndrome, Stevens–Johnson syndrome, or toxic epidermal necrolysis. Five cases of breast cancer in patients who took spironolactone for prolonged periods of time have been reported. Pregnancy and breastfeeding Spironolactone can cross the placenta. Because it is an antiandrogen, however, spironolactone could theoretically have the potential to cause feminization of male fetuses at sufficient doses. Among 31 human newborns exposed to spironolactone in the first trimester, no signs of any specific birth defects were seen. A 2019 systematic review found insufficient evidence that spironolactone causes birth defects in humans. Evidence was insufficient to be certain that it does not. ==Overdose==

Spironolactone is relatively safe in acute overdose. Its oral median lethal dose (LD50) is more than 1,000 mg/kg in mice, rats, and rabbits. No specific antidote for overdose of spironolactone is known. Treatment may consist of induction of vomiting or stomach evacuation by gastric lavage. The treatment of spironolactone overdose is supportive, with the purpose of maintaining hydration, electrolyte balance, and vital functions. Spironolactone should be discontinued in people with impaired kidney function or hyperkalemia. == Interactions ==

Spironolactone often increases serum potassium levels and can cause hyperkalemia, a very serious condition. Therefore, people using this medication should avoid potassium supplements and salt substitutes containing potassium. Physicians must be careful to monitor potassium levels in both males and females who are taking spironolactone as a diuretic, especially during the first 12 months of use and whenever the dosage is increased. Doctors may also recommend that some patients may be advised to limit dietary consumption of potassium-rich foods. Recent data suggest that both potassium monitoring and dietary restriction of potassium intake are unnecessary in healthy young women taking spironolactone for acne Spironolactone has been reported to induce the enzymes CYP3A4 and certain UDP-glucuronosyltransferases , which can result in interactions with various medications. However, metabolites of spironolactone reportedly irreversibly inhibit CYP3A4. In any case, spironolactone has been found to reduce the bioavailability of oral estradiol, which could be due to induction of estradiol metabolism via CYP3A4. Spironolactone has also been found to inhibit UGT2B7. Spironolactone can also have numerous other interactions, most commonly with other cardiac and blood-pressure medications, for instance digoxin. Licorice, which has indirect mineralocorticoid activity by inhibiting mineralocorticoid metabolism, has been found to inhibit the antimineralocorticoid effects of spironolactone. Moreover, the addition of licorice to spironolactone has been found to reduce the antimineralocorticoid side effects of spironolactone in women treated with it for hyperandrogenism, and licorice hence may be used to reduce these side effects in women treated with spironolactone as an antiandrogen who are bothered by them. Aspirin and other NSAIDs have been found to attenuate the diuresis and natriuresis induced by spironolactone, but not to affect its antihypertensive effect. 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 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. Other research contradicts this hypothesis and has suggested that spironolactone might produce antidepressant effect, for instance, in studies showing antidepressant-like effects of spironolactone in animals. ==Pharmacology==

Pharmacodynamics , the major active form of spironolactone. It accounts for about 80% 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. It is also responsible for many of the side effects of spironolactone, such as urinary frequency, dehydration, hyponatremia, low blood pressure, fatigue, dizziness, metabolic acidosis, decreased kidney function, and its risk of hyperkalemia. Due to the antimineralocorticoid activity of spironolactone, levels of aldosterone are significantly increased by the medication, probably reflecting an attempt of the body to maintain homeostasis. It is also primarily responsible for some of its side effects, like breast tenderness, gynecomastia, feminization, and demasculinization in men. Although useful as an antiandrogen in women, who have low testosterone levels compared to men, spironolactone is described as having relatively weak antiandrogenic activity. Spironolactone is a weak steroidogenesis inhibitor. That is, it inhibits steroidogenic enzymes, or enzymes involved in the production of steroid hormones. However, although very high doses of spironolactone can considerably decrease steroid hormone levels in animals, spironolactone has shown mixed and inconsistent effects on steroid hormone levels in clinical studies, even at high clinical doses. The weak steroidogenesis inhibition of spironolactone might contribute to its antiandrogenic efficacy to some degree and may explain its side effect of menstrual irregularities in women. 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. It is notable that spironolactone has been found in vitro to act as a weak inhibitor of 17β-hydroxysteroid dehydrogenase 2, an enzyme that is involved in the conversion of estradiol into estrone. Increased levels of estradiol with spironolactone may be involved in its preservation of bone density and in its side effects such as breast tenderness, breast enlargement, and gynecomastia in women and men. In response to the antimineralocorticoid activity spironolactone, and in an attempt to maintain homeostasis, the body increases aldosterone production in the adrenal cortex. Some studies have found that levels of cortisol, a glucocorticoid hormone that is also produced in the adrenal cortex, are increased as well. Spironolactone "acts at the basolateral side of the upper-distal tubule as well as in the collecting tubule," and does not have glucocorticoid-like effects at these specific sites; it can sometimes be prescribed as an alternative to glucocorticoids for patients with Glucocorticoid-Remediable Aldosteronism characterized by aldosterone excess, In patients "receiving spironolactone, there was a significant positive correlation between the change in cortisol and the change in HbA1c (r = 0.489, P = .003)." Patients taking spironolactone must be monitored for side effects including dizziness, headache, fatigue, diarrhea, hypertriglyceridemia and elevated liver enzymes. Other activities of spironolactone may include very weak interactions with the estrogen and progesterone receptors and agonism of the pregnane X receptor. These activities could contribute to the menstrual irregularities and breast side effects of spironolactone and to its drug interactions, respectively. 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 The bioavailability of spironolactone when taken by mouth is 60 to 90%. The increase in bioavailability is thought to be due to promotion of the gastric dissolution and absorption of spironolactone, as well as due to a decrease of the first-pass metabolism. The relationship between a single dose of spironolactone and plasma levels of canrenone, a major active metabolite of spironolactone, has been found to be linear across a dose range of 25 to 200 mg spironolactone. 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. Spironolactone is bound equivalently to albumin and α1-acid glycoprotein, while canrenone is bound only to albumin. In accordance, a study of high-dosage spironolactone treatment found no change in steroid binding capacity related to SHBG or to corticosteroid-binding globulin (CBG), suggesting that spironolactone does not displace steroid hormones from their carrier proteins. This is in contradiction with widespread statements that spironolactone increases free estradiol levels by displacing estradiol from SHBG. Spironolactone appears to cross the blood–brain barrier. Metabolism in humans. Canrenone may be further reduced (into di-, tetra-, and hexahydrogenated metabolites), hydroxylated, and conjugated (e.g., glucuronidated). These metabolites have much longer elimination half-lives than spironolactone of 13.8 hours, 15.0 hours, and 16.5 hours, respectively, and are responsible for the therapeutic effects of the medication. The 7α-thiomethylated metabolites of spironolactone were not known for many years and it was originally thought that canrenone was the major active metabolite of the medication, but subsequent research identified 7α-TMS as the major metabolite. Spironolactone is hydrolyzed or deacetylated at the thioester of the C7α position into 7α-TS by carboxylesterases. Following formation of 7α-TS, it is S-oxygenated by flavin-containing monooxygenases to form an electrophilic sulfenic acid metabolite. However, hepatic CYP3A4 is likely responsible for the 6β-hydroxylation of 7α-TMS into 6β-OH-7α-TMS. 7α-TMS may also be hydroxylated at the C3α and C3β positions. Spironolactone is dethioacetylated into canrenone. Finally, the C17 γ-lactone ring of spironolactone is hydrolyzed by the paraoxonase PON3. It was originally thought to be hydrolyzed by PON1, but this was due to contamination with PON3. ==Chemistry==

Spironolactone, also known as 7α-acetylthiospirolactone, is a steroidal 17α-spirolactone, or more simply a spirolactone. It can most appropriately be conceptualized as a derivative of progesterone, potent antiandrogenic activity, and strongly reduced progestogenic activity. The C7α substitution is likely responsible for or involved in the antiandrogenic activity of spironolactone, as 7α-thioprogesterone (SC-8365), unlike progesterone, is an antiandrogen with similar affinity to the AR as that of spironolactone. In addition, the C7α substitution appears to be responsible for the loss of progestogenic activity and good oral bioavailability of spironolactone, as SC-5233, the analogue of spironolactone without a C7α substitution, has potent progestogenic activity but very poor oral bioavailability similarly to progesterone. 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 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). ==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. Spironolactone was first synthesized in 1957, and was first marketed, as an antimineralocorticoid, in 1959. Gynecomastia was first reported with spironolactone in 1962, and the antiandrogenic activity of the medication was first described in 1969. This shortly followed the discovery in 1967 that gynecomastia is an important and major side effect of AR antagonists. Spironolactone was first studied in the treatment of hirsutism in women in 1978. It has since become the most widely used antiandrogen for dermatological indications in women in the United States. Spironolactone was first studied as an antiandrogen in transgender women in 1986, and has since become widely adopted for this purpose as well, particularly in the United States where cyproterone acetate is not available. Early oral spironolactone tablets showed poor absorption. The formulation was eventually changed to a micronized formulation with particle sizes of less than 50 μg, which resulted in approximately 4-fold increased potency. ==Society and culture==

Generic names The English, French, and generic name of the medication is spironolactone and this is its , , , , , and . Its name is in Latin, in German, in Spanish and Portuguese, and in Italian (which is also its ). with metolazone as Metolactone, with bendroflumethiazide as Sali-Aldopur, and with torasemide as Dytor Plus, Torlactone, and Zator Plus. Availability Spironolactone is marketed throughout the world. ==Research==

Prostate conditions Spironolactone has been studied at a high dosage in the treatment of benign prostatic hyperplasia (BPH; enlarged prostate). It was found to be better than placebo in terms of symptom relief following three months of treatment. This effect of spironolactone was determined to be independent of its antimineralocorticoid actions. Spironolactone has been studied in fibromyalgia in women. It has also been studied in bulimia nervosa in women, but was not found to be effective. == References ==