There are no published studies addressing the course of action for a patient who accidentally missed a dose of spironolactone.
The manufacturer’s prescribing information gives no guidance about the effect of a missed dose of spironolactone.1 Spironolactone is currently prescribed at levels that range from up to 100 mg/day for hypertension, up to 200 mg/day for edema, and up to 400 mg/day for primary hyperaldosteronism.1 Historically it has been given at therapeutic doses up to 500 mg/day.2 However, there is no data that supports taking two doses of spironolactone close together to compensate for a missed dose.
The elimination half-life of spironolactone and its various metabolites is relatively long and ranges from 10 to 35 hours.3–5 These half-lives are even longer in patient with cirrhosis.6 The effects of spironolactone and its metabolites persist for several days after discontinuation.7
Spironolactone is not recommended as a first-line drug for hypertension.8 Patients taking spironolactone for resistant hypertension are typically taking more than one antihypertensive medication. It might then be inferred that the effect of a single missed dose on blood pressure would be small compared to drugs with a shorter half-life, and in patients taking only one antihypertensive medication, but this has not been studied in controlled trials.
- Aldactone-spironolactone [package insert], New York, NY: Pfizer, Inc; 2016.
- BatterinkJ, Sn S, Am T, et al. Spironolactone for hypertension (review). Cochrane Database Syst Rev 2010;(8): 8-10.
- ClinicalKeydrug monograph: spironolactone. Elsevier; 2018. https://www.clinicalkey.com/#!/content/drug_monograph/6-s2.0-572. Accessed September 4, 2018.
- Yang J, Young MJ. Mineralocorticoid receptor antagonists - pharmacodynamics and pharmacokinetic differences. CurrOpin Pharmacol 2016; 27 : 78-85.
- Kolkhof P, Borden SA. Molecular pharmacology of the mineralocorticoid receptor: Prospects for novel therapeutics. Mol Cell Endocrinol 2012; 350 (2): 310-317.
- Sungaila I, Bartle WR, Walker SE, et al. Spironolactone pharmacokinetics and pharmacodynamics in patients with cirrhotic ascites. Gastroenterology 1992; 102 (5): 1680-1685.
- Sica DA. Pharmacokinetics and pharmacodynamics of mineralocorticoid blocking agents and their effects on potassium homeostasis. Heart Fail Rev 2005; 10 (1): 23-29.
- Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2017.