People with acute decompensated heart failure resistant to loop diuretics lost the excess fluid with high-dose spironolactone (Aldactone), a prospective single-center study found.
Among 19 people who could not lose weight on IV furosemide, spironolactone 100 or 200 mg daily was associated with consistent and “clinically important” daily weight loss up to 5 days, according to a group of investigators led by Shweta Bansal, MD, of the University of Texas Health at San Antonio and South Texas Veterans Health Care System.
By day 4, dyspnea improved at least three levels on the Likert scale in 14 out of the 19 people receiving high-dose spironolactone in the study, published online in Annals of Internal Medicine.
The results of the study appeared to run counter to those of the ATHENA-HF trial, in which 100-mg spironolactone was of no help for weight loss, dyspnea, or heart failure severity in acute heart failure.
However, patient selection could be the reason, suggested ATHENA principal investigator Javed Butler, MD, MPH, of the University of Mississippi in Jackson.
“This study builds from ATHENA HF, where high does spironolactone was given at the time of admission, without demonstrating diuretic resistance. While small and non-randomized, this study elegantly shows the benefit of this strategy when targeting those specifically who are diuretic resistant,” he commented to MedPage Today.
Bansal and colleagues noted that besides being small, their study lacked a control group and did not measure readmission rates.
“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,” they said.
“These results highlight the need for a larger outcomes study of high dose mineralocorticoid receptor antagonist use in acute heart failure patients who are diuretic resistant,” Butler agreed.
Bansal’s study was based on people recently hospitalized for heart failure with reduced or preserved ejection fraction.
Heart failure patients who took 100 mg spironolactone on the first day and still lost less than 0.5 kg (but did not have large increases in serum creatinine) were able to switch to 200 mg spironolactone daily.
Weight loss and reduced dyspnea were not accompanied by worsening hyperkalemia or renal function, though one patient died “under complex circumstances without a satisfactory explanation,” Bansal and colleagues noted.
That patient had lost nearly 8 lbs by day 4, when she developed abdominal discomfort and had a blood pressure of 91/45 mm Hg and a potassium level of 5.2 mmol/L. Despite getting IV fluids to support her blood pressure, she died after cardiac arrest.
No patient had potassium exceed 5.5 mmol/L, although three people received a total of five doses of potassium-lowering patiromer (Veltassa).
Bansal reported grants from Relypsa during the conduct of the study.