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Drug Safety in Patients With Heart Failure

Drug Safety in Patients With Heart Failure In reviewing the safety of various medications for patients with heart failure, Amabile and Spencer1 have provided clinicians with an excellent resource. Although they offer the disclaimer that their review is not exhaustive, they have omitted an exceptionally important cause of drug-related harm in patients with heart failure. In appropriate patients, spironolactone improves cardiac morbidity and mortality with a relatively low incidence of hyperkalemia.2 However, the reality is that spironolactone is often prescribed to patients with additional risk factors (drug and nondrug) for hyperkalemia, with inadequate clinical and laboratory monitoring, and sometimes to patients with no clear indication for the drug to begin with.3 While several reports describe life-threatening hyperkalemia resulting from the combination of spironolactone and angiotensin-converting enzyme inhibitors, highlighting this drug interaction for clinicians,4-8 they tell us nothing of the sudden prehospital deaths from hyperkalemia that might simply have been ascribed to heart disease. Drug safety is a complex topic, and Amabile and Spencer1 should be commended for their efforts. However, discussions of disease-specific drug safety should necessarily involve medications used to treat the disorder of interest. We submit that spironolactone-associated hyperkalemia may be one of the most significant causes of drug-related harm facing patients with heart failure. Correspondence: Dr Juurlink, General Internal Medicine, Clinical Pharmacology & Toxicology, and Clinical Epidemiology, Sunnybrook and Women’s College Health Sciences Centre, 2075 Bayview Ave, G Wing 106, Toronto, Ontario, Canada M4N 3M5 (dnj@ices.on.ca). References 1. Amabile CMSpencer AP Keeping your patient with heart failure safe: a review of potentially dangerous medications. Arch Intern Med 2004;164709- 720PubMedGoogle ScholarCrossref 2. Pitt BZannad FRemme WJ et al. the Randomized Aldactone Evaluation Study Investigators, The effect of spironolactone on morbidity and mortality in patients with severe heart failure. N Engl J Med 1999;341709- 717PubMedGoogle ScholarCrossref 3. Bozkurt BAgoston IKnowlton AA Complications of inappropriate use of spironolactone in heart failure when an old medicine spirals out of new guidelines. J Am Coll Cardiol 2003;41211- 214PubMedGoogle ScholarCrossref 4. Schepkens HVanholder RBilliouw JMLameire N Life-threatening hyperkalemia during combined therapy with angiotensin-converting enzyme inhibitors and spironolactone: an analysis of 25 cases. Am J Med 2001;110438- 441PubMedGoogle ScholarCrossref 5. Svensson MGustafsson FGalatius SHildebrandt PRAtar D Hyperkalaemia and impaired renal function in patients taking spironolactone for congestive heart failure: retrospective study. BMJ 2003;3271141- 1142PubMedGoogle ScholarCrossref 6. Vanpee DSwine CH Elderly heart failure patients with drug-induced serious hyperkalemia. Aging (Milano) 2000;12315- 319PubMedGoogle Scholar 7. Wrenger EMuller RMoesenthin MWelte TFrolich JCNeumann KH Interaction of spironolactone with ACE inhibitors or angiotensin receptor blockers: analysis of 44 cases. BMJ 2003;327147- 149PubMedGoogle ScholarCrossref 8. Berry CMcMurray JJ Serious adverse events experienced by patients with chronic heart failure taking spironolactone. Heart 2001;85E8PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Drug Safety in Patients With Heart Failure

Drug Safety in Patients With Heart Failure

Abstract

In reviewing the safety of various medications for patients with heart failure, Amabile and Spencer1 have provided clinicians with an excellent resource. Although they offer the disclaimer that their review is not exhaustive, they have omitted an exceptionally important cause of drug-related harm in patients with heart failure. In appropriate patients, spironolactone improves cardiac morbidity and mortality with a relatively low incidence of hyperkalemia.2 However, the reality is that...
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Publisher
American Medical Association
Copyright
Copyright © 2005 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.165.1.118-a
Publisher site
See Article on Publisher Site

Abstract

In reviewing the safety of various medications for patients with heart failure, Amabile and Spencer1 have provided clinicians with an excellent resource. Although they offer the disclaimer that their review is not exhaustive, they have omitted an exceptionally important cause of drug-related harm in patients with heart failure. In appropriate patients, spironolactone improves cardiac morbidity and mortality with a relatively low incidence of hyperkalemia.2 However, the reality is that spironolactone is often prescribed to patients with additional risk factors (drug and nondrug) for hyperkalemia, with inadequate clinical and laboratory monitoring, and sometimes to patients with no clear indication for the drug to begin with.3 While several reports describe life-threatening hyperkalemia resulting from the combination of spironolactone and angiotensin-converting enzyme inhibitors, highlighting this drug interaction for clinicians,4-8 they tell us nothing of the sudden prehospital deaths from hyperkalemia that might simply have been ascribed to heart disease. Drug safety is a complex topic, and Amabile and Spencer1 should be commended for their efforts. However, discussions of disease-specific drug safety should necessarily involve medications used to treat the disorder of interest. We submit that spironolactone-associated hyperkalemia may be one of the most significant causes of drug-related harm facing patients with heart failure. Correspondence: Dr Juurlink, General Internal Medicine, Clinical Pharmacology & Toxicology, and Clinical Epidemiology, Sunnybrook and Women’s College Health Sciences Centre, 2075 Bayview Ave, G Wing 106, Toronto, Ontario, Canada M4N 3M5 (dnj@ices.on.ca). References 1. Amabile CMSpencer AP Keeping your patient with heart failure safe: a review of potentially dangerous medications. Arch Intern Med 2004;164709- 720PubMedGoogle ScholarCrossref 2. Pitt BZannad FRemme WJ et al. the Randomized Aldactone Evaluation Study Investigators, The effect of spironolactone on morbidity and mortality in patients with severe heart failure. N Engl J Med 1999;341709- 717PubMedGoogle ScholarCrossref 3. Bozkurt BAgoston IKnowlton AA Complications of inappropriate use of spironolactone in heart failure when an old medicine spirals out of new guidelines. J Am Coll Cardiol 2003;41211- 214PubMedGoogle ScholarCrossref 4. Schepkens HVanholder RBilliouw JMLameire N Life-threatening hyperkalemia during combined therapy with angiotensin-converting enzyme inhibitors and spironolactone: an analysis of 25 cases. Am J Med 2001;110438- 441PubMedGoogle ScholarCrossref 5. Svensson MGustafsson FGalatius SHildebrandt PRAtar D Hyperkalaemia and impaired renal function in patients taking spironolactone for congestive heart failure: retrospective study. BMJ 2003;3271141- 1142PubMedGoogle ScholarCrossref 6. Vanpee DSwine CH Elderly heart failure patients with drug-induced serious hyperkalemia. Aging (Milano) 2000;12315- 319PubMedGoogle Scholar 7. Wrenger EMuller RMoesenthin MWelte TFrolich JCNeumann KH Interaction of spironolactone with ACE inhibitors or angiotensin receptor blockers: analysis of 44 cases. BMJ 2003;327147- 149PubMedGoogle ScholarCrossref 8. Berry CMcMurray JJ Serious adverse events experienced by patients with chronic heart failure taking spironolactone. Heart 2001;85E8PubMedGoogle ScholarCrossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Jan 10, 2005

Keywords: heart failure,drug safety

References