Assessment every 6 months

• clinical assessment of functional status

• Fluid staus

  • body weight

  • JVP

  • peripheral oedema

  • postural hypotension

• Cardiac exam

  • rhythm

    • ecg

  • heart sounds

  • chest crepitations

• cognitive and nutritional status

Testing

• electrolytes and cr assess before initiation then at one week if HF or 4-6wk if for HTN

• every 3-6 months in lower risk

Spironolactone

• hyperkalaemia

  • elderly

    • >60

  • DM

  • impaired renal function

    • stage 3 or above

  • concurrent:

    • NSDAID

    • ACEi

    • Cyclosporin

Thiazide or loop

• hyponatramia and hypokalaemia

• mild hypercalcaemia

In hyperterthension

• electolytes

  • within 4-6 weeks of starting

  • every 6-12 months

  • clinical condition changes or potentially interacting drug added

• if hypokalameia

  • review therapy

  • increase intake of K

  • consider elevated aldosterone

• if serum cr increase >20% or egfr falls >15%

  • remeasure 2weeks

  • if continues to worsen consider specialist advice

In heart failure

• renal function

  • at baseline then @ 1wk then

  • 1-2 weeks after each dose increase in low risk

  • 5-7d after increase in high risk

  • during illness

  • 3-6mo in stable higher risk

  • annually in stable lower risk

• if hypokalaemia

  • review

  • increase K

• if serum cr ises >20% or eGFR falls >15%

  • remeasure 2 weeks

  • consider referral

Potassium sparing

in hypertension

• electrolytes

  • baseline (shouldn’t be started in K >5)

  • after 5-7 days with dose titration

  • every 5-7d until K stable

  • 6-12mo low risk

  • high risk (older, renal/cardiac dysfunction) every 4-8wk

in heart failure

• renal function

  • at baseline

  • q5-7d with titration

  • every 5-7d until K stable

  • 6-12mo for low risk

  • high risk every 4-8 wk

• if K 5.5-5.9 or cr rises significantly above baseline but \<2000

  • reduce to 25mg on alternate days

  • monitor renal function

• K >6 or Cr >200

  • stop

  • seek specialist advice

Interactions

• NSAID

  • Thiazide/loops

    • fluid retention

      • antagonise effects of diuretics

    • if combined iwth ACEi increased effects

  • Spironolactone

    • increase risk of hyperkalaemia and renal fialure

    • avoid with ACEi

• Digoxin

  • Thiaizde/loops

    • cause hypokalaemia

      • predispose to digoxin toxicity

  • Spironolactone

    • increase plasma concentration of digoxin

    • spiro and its metabolite may interfere with digoxin assay = difficult to evaulate

    • monitor closely

• ACEi/ARB

  • Thiazide/loop

    • first dose hypotension may occur

      • especially if high dose diuretic

    • potetiate ACEi induced AKI

      • ++ if NSAID

  • Spironolactone

    • increase risk of severe hyperkalaemia

    • keep below 25mg od

• Lithium

  • thiazide/loop

    • increase lithium levels

      • lethargy

      • muscle weakness

      • lack of coordination

  • Spironolactone

    • clearance may be reduced

• Cyclosporin

  • Thiazide/loop

    • nephrotoxicity reported

    • increase risk of gout

  • Spironolactone

    • may result in hyperkalaemia