Spironolactone is a less common antihypertensive medication because it is not recommended for use as a first-line treatment for hypertension.1 It is the preferred drug to use when hypertension is related to primary aldosteronism or in patients with resistant hypertension.
According to Medicare Part D claims data from 2016, 1 150 481 beneficiaries took spironolactone between 2012 and 2016.2 These numbers compare with the most commonly prescribed anti-hypertensive, lisinopril, which was prescribed to 46 573 906 beneficiaries, alone or in combination, over the same period. Spironolactone is also used to treat a number of other conditions including heart failure, primary aldosteronism and fluid retention due to cardiac, liver, and kidney disease.3
Spironolactone is the most commonly used aldosterone receptor antagonist in the treatment of resistant hypertension.4 Resistant hypertension is defined as high blood pressure that is uncontrolled despite the use of three complementary antihypertensives or blood pressure that requires the use of 4 or more medications to achieve control. It affects about 13% to 17% of the adult population in the US, depending on which cutoff is used (130/80 or 140/90) to define control.1
Current guidelines1 recommend adding spironolactone to multidrug regimens for treatment of resistant hypertension because of its proven effectiveness over placebo and over other antihypertensives in these patients.5–7 But studies of trends in use of antihypertensives suggest that spironolactone use is below expected levels given predicted rates of resistant hypertension.4,8,9
Some analyses of prescribing trends suggest that the use of spironolactone among patients with treatment resistant hypertension is increasing. Hwang et al analyzed prescription claims data from the Marketscan database of employer-based insurance programs representing nearly 30 million Americans between 2008 and 2014.4 Spironolactone was used in 7% of treatment resistant hypertension episodes in 2008 compared to 9.5% of episodes in 2014, a statistically significant rise. Spironolactone use increased by nearly 38% over the same time period, but still remained lower than expected given current guidelines.
References
- 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. J Am Coll Cardiol 2018; 71 (19): e127-e248.
- US Center for Medicare & Medicaid Services. Medicare Drug Spending Part D All Drugs. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Information-on-Prescription-Drugs/2015Medicare.html. Accessed August 2, 2018.
- Aldactone (spironolactone) [package insert]. New York, NY: Pfizer Labs; 2018.
- Hwang AY, Dave C, Smith SM. Trends in antihypertensive medication use among US patients with resistant hypertension, 2008 to 2014. Hypertension 2016; 68 (6): 1349-1354.
- Liu L, Xu B, Ju Y. Addition of spironolactone in patients with resistant hypertension: a meta-analysis of randomized controlled trials. Clin Exp Hypertens 2017; 39 (3): 257-263.
- Krieger EM, Drager LF, Giorgi D, et al. Spironolactone versus clonidine as a fourth-drug therapy for resistant hypertension: the ReHOT randomized study (Resistant Hypertension Optimal Treatment). Hypertens 2018; 71 (4): 681-690.
- Vaclavik J, Sedlak R, Plachy M, et al. Addition of spironolactone in patients with resistant arterial hypertension (ASPIRANT): a randomized, double-blind, placebo-controlled trial. Hypertens 2011; 57 (6): 1069-1075.
- Fontil V, Pletcher MJ, Khanna R, Guzman D, Victor R, Bibbins-Domingo K. Physician underutilization of effective medications for resistant hypertension at office visits in the United States: NAMCS 2006-2010. J Gen Intern Med 2014; 29 (3): 468-476.
- Hanselin MR, Saseen JJ, Allen RR, Marrs JC, Nair K V. Description of antihypertensive use in patients with resistant hypertension prescribed four or more agents. Hypertens 2011; 58 (6): 1008-1013.
