Use Spironolactone or Eplerenone When Prescribing Thiazide Diuretic
The last post discussed the way mineralocorticoid receptor (MR) blockers like spironolactone, eplerenone, and finerenone are precision medicines that slow the progression of chronic kidney disease. That protection reflects a fundamental fact about chronic kidney disease, congestive heart failure, and other complications of high blood pressure and diabetes.
Thiazide-type diuretics like hydrochlorothiazide (HCTZ) are among the most prescribed medications used to treat high blood pressure. One of the most common and dangerous side effects of HCTZ is low potassium from increased aldosterone effects caused by HCTZ treatment. Most patients with hypertension also have increased abdominal fat which causes increased aldosterone and cortisol effects which are part of the reason the pressure is elevated in the first place. Aldosterone and cortisol both activate the MR receptor to increase oxidant production and contribute directly to the origins of high blood pressure, chronic kidney disease, and congestive heart failure. Aldosterone is especially important in contributing to the development of resistant hypertension. Blocking the MR receptor with spironolactone, eplerenone, or finerenone therefore directly interferes with the biology that causes hypertension and the later complications of chronic kidney disease, artery disease, and heart failure.
If you start treating high blood pressure with lisinopril as the first drug and it is poorly controlled adding HCTZ it makes sense. You can buy lisinopril/HCTZ for between $5 and $10 a month. If the pressure is still not controlled adding low dose spironolactone (12.5) mg and reducing the lisinopril dose is very effective and blocks angiotensin II, cortisol, and aldosterone while providing better blood pressure control and greater protection from chronic kidney disease, heart failure, and other organ damage. Early in the disease process using these medications is safer than after the kidney is already damaged. When starting or changing doses of these drugs check potassium level and kidney function frequently. It is important to move beyond thinking that is limited to risk factor control and to instead use medications that protect cells and organs.