It always get on my nerves to hear about drug shortages of important medications. Last week, I have been told that spironolactone is on back order nationwide. It is difficult to know when supply will be available again. So many clinicians need to think about a “Plan B” for patients currently taking spironolactone.

Spironolactone is a potassium sparing diuretic which is also an aldosterone antagonist with anti-androgen activities.  In any case, the common uses of spironolactone include:

  • Treatment of Primary Aldosteronism
  • Resistant Hypertension
  • Congestive Heart Failure
  • Ascites in Adults with Cirrhosis
  • Hirsutism or Hair Loss in Female

The consideration of alternatives must include the indications as well as the pharmacology of the medication.

Here are my humble thoughts:

For treatment of resistant hypertension, there are definitely many other options. If spironolactone is used primarily for the potassium sparing effect, then another potassium sparing diuretic such as triamterene or amiloride may be considered.

In patients who are taking spironolactone for heart failure or ascites with cirrhosis, one may need to replace with a potassium sparing diuretic that also antagonizes aldosterone. In these situations, eplerenone may be more suitable alternative, as it is marketed as a selective aldosterone receptor antagonist and with some evidence for use in heart failure. In Ontario, eplerenone is only covered via Exceptional Access Program in patients meeting the following clinical criteria:

For the treatment of patients who have heart failure and left ventricular systolic dysfunction due to acute myocardial infarction. Patients must have: • An ejection fraction ≤ 40% AND • Prior trial of spironolactone but experienced severe symptomatic (painful) gynecomastia

In patients who are taking spironolactone for off label indications such as hair loss or hirsutism, one should be looking for alternatives that also possess antiandrogen activities. Eplerenone has been developed specifically to have much less affinity for the androgen or progestin receptors, so its use is unlikely to offer equivalent benefits. Likewise, other potassium-sparing diuretics are likely not appropriate choices here. There is no easy option but other anti-androgen treatment options include cyproterone acetate, flutamide and 5-alpha reductase inhibitors (e.g. finasteride).

Depending on the indication(s) of spironolactone, there may or may not be equivalent treatment options to consider. Let’s hope the drug shortage will be resolved soon.

Thank you for reading my post.