Pharmacodynamics of spironolactone

The pharmacodynamics of spironolactone, an antimineralocorticoid and antiandrogen medication, concern its mechanisms of action, including its biological targets and activities, as well as its physiological effects. The pharmacodynamics of spironolactone are characterized by high antimineralocorticoid activity, moderate antiandrogenic activity, and weak steroidogenesis inhibition. In addition, spironolactone has sometimes been found to increase estradiol and cortisol levels and hence could have slight indirect estrogenic and glucocorticoid effects. The medication has also been found to interact very weakly with the estrogen and progesterone receptors, and to act as an agonist of the pregnane X receptor. Likely due to increased activation of the estrogen and/or progesterone receptors, spironolactone has very weak but significant antigonadotropic effects.[5][6]

Spironolactone has a very short biological half-life and is considered to be a prodrug; hence, its active metabolites are responsible for most of its pharmacodynamics. The major active forms of spironolactone include 7α-thiomethylspironolactone (7α-TMS) and canrenone (7α-desthioacetyl-δ6-spironolactone), while more minor metabolites of spironolactone include 7α-thiospironolactone (7α-TS), 6β-hydroxy-7α-thiomethylspironolactone (6β-OH-7α-TMS), and a number of others.

Aside from its primary mechanisms of action of antimineralocorticoid and antiandrogenic action, spironolactone has been found in preclinical research to interact very weakly with the progesterone and estrogen receptors and to have very weak mixed progestogenic and antiprogestogenic activity as well as very weak mixed estrogenic and antiestrogenic activity.[7][6][8] The clinical significance of these actions, if any, is uncertain.[8] However, a small clinical study found that high doses of spironolactone had neither progestogenic nor antiprogestogenic effects in women.[8][9] In any case, if one or both of these actions are clinically relevant, they might contribute to the menstrual irregularities and breast side effects of spironolactone.[6][10] Spironolactone is also an agonist of the pregnane X receptor,[11] and is able to induce the expression of CYP3A4 and P-glycoprotein in the body via this action.[12][13][14] This effect may contribute to the drug interactions of spironolactone.[12][13][14]

Antimineralocorticoid activity

Spironolactone at steroid hormone receptors[15][16]
SiteValue (nM)TypeActionSpeciesRef
AR39.4
120
13–670
>20,000
Ki
IC50a 
IC50b
EC50
AntagonistHuman[17]
[18]
[19][20]
[20]
ERc>1,100
5,700
Ki
IC50b
AntagonistHuman[17]
[19]
ERα5,970–>20,000
>20,000
IC50b
EC50
AgonistHuman[21][20]
[20]
ERβ4940–>20,000
3,300
IC50b
EC50
InconsistentHuman[21][20]
[20]
GR32.6
1,400
2,410–6,920
>20,000
Ki
IC50a
IC50b
EC50
AntagonistHuman[17]
[18]
[21][22]
[20]
MR2.32
49
2.4–60
17.7
Ki
IC50a
IC50b
Kb
AntagonistHuman[17]
[18]
[19][18]
[17]
PRc400
650
>25,000
740–2,619
Ki
IC50a
IC50b
EC50
AgonistHuman[17]
[18]
[19][22]
[21][19]
PR-B4,000
>20,000
IC50b
EC50
AntagonistHuman[20]
[20]
The ranges are the values reported in different studies. a = Binding inhibition. b = Functional antagonism. c = Subtype unspecified (probably ERα and PR-B, however).

Spironolactone inhibits the effects of mineralocorticoids, namely, aldosterone, by displacing them from MR in the cortical collecting duct of kidney nephrons. This decreases the reabsorption of sodium and water while limiting the excretion of potassium (A K+ sparing diuretic). The medication has a slightly delayed onset of action, and so it takes several days for diuresis to occur. This is because the MR is a nuclear receptor which works through regulating gene transcription and gene expression, in this case, to decrease the production and expression of ENaC and ROMK electrolyte channels in the distal nephrons. In addition to direct antagonism of the MRs, the antimineralocorticoid effects of spironolactone may also in part be mediated by direct inactivation of 11β-hydroxylase and aldosterone synthase (18-hydroxylase), enzymes involved in the biosynthesis of mineralocorticoids. If levels of mineralocorticoids are decreased then there are lower circulating levels to compete with spironolactone to influence gene expression as mentioned above.[23] The onset of action of the antimineralocorticoid effects of spironolactone is relatively slow, with the peak effect sometimes occurring 48 hours or more after the first dose.[1][24]

Canrenone is an antagonist of the MR similarly to spironolactone,[25] but is slightly more potent in comparison.[24][26] It has been determined that 7α-TMS accounts for around 80% of the potassium-sparing effect of spironolactone[1][2][3] while canrenone accounts for the remaining approximate 10 to 25%.[4] In accordance, 7α-TMS occurs at higher circulating concentrations than does canrenone in addition to having a higher relative affinity for the MR.[2]

Antiandrogenic activity

Spironolactone is an antagonist of the AR, the biological target of androgens like testosterone and DHT.[27][28] Its affinity for the AR has been found to vary widely between different studies, with a range of 2.7 to 67% of that of DHT.[29][30][31][32] One study found affinities for the AR of 3.0% for spironolactone, 4.2% for 7α-TMS, and 3.1% for 7α-TS.[30] Conversely, the affinity of canrenone for the AR was found to be 0.84% of that of DHT in another study, relative to 67% for spironolactone.[32] However, another study found the affinity of canrenone for the AR to be 2.5 to 14%, relative to 4.1 to 31% in the case of spironolactone.[33] Spironolactone antagonizes the effects of exogenous testosterone administered to castrated animals.[29] It works by binding to the AR and displacing androgens like testosterone and DHT from the receptor, thereby reducing its activation by these hormones.[27]

The AR antagonism of spironolactone mostly underlies its antiandrogenic activity and is the major mechanism responsible for its therapeutic benefits in the treatment of androgen-dependent conditions like acne, hirsutism, and pattern hair loss and its usefulness in hormone therapy for transgender women.[27][8] In addition, the AR antagonism of spironolactone is involved in its feminizing side effects in men like gynecomastia.[27] Spironolactone has been found to produce gynecomastia without changes in testosterone or estradiol levels, implicating AR antagonism in this side effect.[29] Gynecomastia is a major known side effect of AR antagonists.[34]

Spironolactone, similarly to other steroidal antiandrogens such as cyproterone acetate, is actually not a pure, or silent, antagonist of the AR, but rather is a weak partial agonist with the capacity for both antagonistic and agonistic effects.[35][36][37] However, in the presence of sufficiently high levels of potent full agonists like testosterone and DHT (the cases in which spironolactone is usually used even with regards to the "lower" relative levels present in females),[37] spironolactone will behave more similarly to a pure antagonist. Nonetheless, there may still be a potential for spironolactone to produce androgenic effects in the body at sufficiently high dosages and/or in those with very low endogenous androgen concentrations. As an example, one condition in which spironolactone is contraindicated is prostate cancer in men being treated with androgen deprivation therapy,[38] as spironolactone has been shown in vitro to significantly accelerate carcinoma growth in the absence of any other androgens.[35] In accordance, two case reports have described significant worsening of prostate cancer with spironolactone treatment in patients with the disease, leading the authors to conclude that spironolactone has the potential for androgenic effects in some contexts and that it should perhaps be considered to be a selective androgen receptor modulator (SARM), albeit with mostly antagonistic effects.[39][40]

Canrenone binds to and blocks the AR in vitro.[28] However, relative to spironolactone, canrenone is described as having very weak affinity for the AR.[41] In accordance, replacement of spironolactone with canrenone in male patients has been found to reverse spironolactone-induced gynecomastia, suggesting that canrenone is comparatively much less potent in vivo as an antiandrogen.[28] As such, based on the above, the antiandrogenic effects of spironolactone are considered to be largely due to other metabolites rather than due to canrenone.[28][42][43] In accordance, 7α-TS and 7α-TMS have been found to possess approximately equivalent affinity for the rat prostate AR relative to that of spironolactone, thus likely accounting for the retention of the antiandrogenic activity of spironolactone.[30]

Steroidogenesis inhibition

Spironolactone is sometimes able to significantly lower testosterone levels at high dosages in spite of not acting as an antigonadotropin, and this is thought to be due to direct enzymatic inhibition of 17α-hydroxylase and 17,20-lyase, enzymes necessary for the biosynthesis of testosterone.[29][44][45][46] Although spironolactone is said to be a relatively weak inhibitor of 17α-hydroxylase and 17,20-lyase,[47][29] at least compared to more potent steroidogenesis inhibitors like ketoconazole and abiraterone acetate (which can reduce testosterone concentrations to castrate levels), this action may contribute to a significant portion of the antiandrogenic activity of spironolactone, for instance lowering testosterone levels in women with hyperandrogenism and in transgender women.[48][49][50] Canrenone inhibits steroidogenic enzymes such as 17α-hydroxylase, 17,20-lyase, 11β-hydroxylase, cholesterol side-chain cleavage enzyme, and 21-hydroxylase similarly to spironolactone, but is more potent in doing so in comparison.[51] In spite of the findings of spironolactone and canrenone on these steroidogenic enzymes however, spironolactone has shown mixed and highly inconsistent effects on steroid hormone levels in clinical studies.[29][8] In some studies, it significantly lowers testosterone levels, whereas in other studies, testosterone and estradiol levels remain unchanged, even at high dosages.[29][52][53] It has been suggested that spironolactone may weakly and partially inhibit 17α-hydroxylase, which in turn results in upregulation of the HPG axis such that steroid hormone levels remain normal.[29] Conversely however, inhibition of 17α-hydroxylase in the ovary may disrupt the menstrual cycle and thereby result in menstrual irregularities.[29]

Animal studies have found that spironolactone inhibits testicular CYP450-mediated steroidogenesis by 5 to 75% across a dosage range of 1 to 100 mg/kg, with 50% inhibition occurring at a dose of 40 mg/kg.[29] A decrease in the production of testosterone and 17α-hydroxyprogesterone due to inhibition of steroidogenic enzymes like 17α-hydroxylase has been found to occur at dosages of 40 to 200 mg/kg.[29] For comparison, the clinical dosage range of spironolactone in humans is usually about 4 to 8 mg/kg.[29]

There is also mixed/conflicting evidence that spironolactone may inhibit 5α-reductase, and thus the synthesis of the potent androgen DHT from testosterone, to some extent.[27][54][55][56][57] However, the combination of spironolactone and the potent 5α-reductase inhibitor finasteride has been found to have significant improved effectiveness in the treatment of hirsutism relative to spironolactone therapy alone, suggesting that any inhibition of 5α-reductase by spironolactone is only weak or at best incomplete.[57] Spironolactone has been found not to have activity as an aromatase inhibitor.[58][59]

Estrogenic activity

Spironolactone has been found to directly interact with the ER.[7] One study found that spironolactone did not interact with the human ER at a specific concentration range tested.[60] However, a subsequent study found that the medication did interact with the human ER at higher concentrations, albeit with very low affinity (Ki = 20 µM).[7] In the same study, spironolactone was administered to rats and found to produce mixed estrogenic and antiestrogenic or selective estrogen receptor modulator (SERM)-like effects that were described as very similar to those of tamoxifen.[7] In spite of the fact that tamoxifen had two orders of magnitude higher affinity for the ER than did spironolactone, the two medications showed similar potency in vivo.[7] The likelihood of spironolactone interacting with the ER itself is remote in consideration of its very low affinity for the receptor in vitro.[6] However, metabolism of spironolactone may result in metabolites with greater ER affinity, which might account for the activity.[7][6]

The authors of the study concluded that direct interaction of spironolactone (and/or its metabolites) with the ER could be involved in the gynecomastia, feminization, and effects on gonadotropin levels that the medication is associated with.[7] Subsequently, it has also been suggested that, as a SERM-like medication, ER agonistic activity of spironolactone in the pituitary gland could be responsible for its antigonadotropic effects while ER antagonstic activity of spironolactone in the endometrium could be responsible for the menstrual disturbances that are associated with it.[6] Such actions might explain these effects of spironolactone in light of the finding that it is not significantly progestogenic or antiprogestogenic in women even at high dosages.[8][9][6]

In accordance, a study found that in women treated with a GnRH analogue, spironolactone therapy almost completely prevented the bone loss that is associated with these medications, whereas treatment with the selective AR antagonist flutamide had no such effect.[61][62] Other studies have also found an inverse relationship between spironolactone and decreased bone mineral density and bone fractures in men.[63][64] Estrogens are well known for maintaining and having positive effects on bone, and it has been suggested that the estrogenic activity of spironolactone may be involved in its positive effects on bone mineral density.[61][62][65] However, it should also be noted that high levels of aldosterone have been associated with adverse bone changes, and so the antimineralocorticoid activity of spironolactone might partially or fully be responsible for these effects as a potential alternative explanation.[64]

In addition to direct interaction with the ER, spironolactone also has some indirect estrogenic activity, which it mediates via several actions, including:

  • By acting as an antiandrogen, as androgens can suppress both estrogen production and signaling (e.g., in the breasts).[28][66]
  • Inhibition of the conversion of estradiol to estrone, resulting in an increase in the ratio of circulating estradiol to estrone.[58] Estradiol is far more potent than estrone as an estrogen, which is comparatively almost inactive.[67][68]
  • Enhancement of the rate of peripheral conversion of testosterone into estradiol, thus decreasing the ratio of circulating testosterone to estradiol.[49]

Spironolactone has been found to act as a reversible inhibitor of human 17β-hydroxysteroid dehydrogenase 2 (17β-HSD2), albeit with weak potency (Ki = 0.25–2.4 μM; IC50 = 0.27–1.1 μM).[69][70][71][59] C7α thioalkyl derivatives of spironolactone like the 7α-thioethyl analogue were found to inhibit the enzyme with greater potency, suggesting that the actual active metabolites of spironolactone like 7α-TMS might be more potent inhibitors.[69][59] 17β-HSD2 is a key enzyme responsible for inactivation of estradiol into estrone in various tissues, and inhibition of 17β-HSD2 by spironolactone may be involved in the gynecomastia and altered ratio of circulating testosterone to estradiol associated with the medication.[58][72] Spironolactone has also been associated with positive effects on bone, and it is notable that 17β-HSD2 inhibitors are under investigation as potential novel treatments for osteoporosis due to their ability to prevent estradiol inactivation in this tissue.[73][74] In contrast to 17β-HSD2, spironolactone does not appear to inhibit 17β-hydroxysteroid dehydrogenase 1 (17β-HSD1) in vitro.[29]

Progestogenic activity

Spironolactone has weak progestogenic activity in bioassays.[47][75] Its actions in this regard are a result of direct agonist activity at the PR, though with a very low half-maximal potency.[76] Spironolactone's progestogenic activity has been suggested to be involved in some of its side effects,[10] including the menstrual irregularities seen in women and the undesirable serum lipid profile changes that are seen at higher doses.[77][78][79] It has also been suggested to augment the gynecomastia caused by the estrogenic effects of spironolactone,[80] as progesterone is known to be involved in mammary gland development.[81]

Although it has been widely stated that the menstrual irregularities associated with spironolactone are due to its progestogenic activity, and although animal studies (involving both rabbits and rhesus monkeys) have shown clear progestogenic effects,[82] the dosages of spironolactone used in animals to produce progestogenic effects were very high, and no evidence of progestogenic nor antiprogestogenic effects (as assessed by endometrial changes) have been observed in women even with high clinical dosages of spironolactone treatment.[8][9] As such, it has been stated that the progestogenic potency of spironolactone is below the level of clinical significance in humans and that the menstrual abnormalities associated with the medication must have a different cause.[8][9] Other possible mechanisms of the menstrual disturbances associated with spironolactone that have been suggested include interference with the hypothalamic–pituitary–gonadal axis, inhibition of enzymatic steroidogenesis,[28] and mixed estrogenic and antiestrogenic activity.[6][8][9]

Antigonadotropic effects

Pure AR antagonists like flutamide and bicalutamide are potent progonadotropins with indirect estrogenic activity in males.[83] This is because they block the AR in the pituitary gland and hypothalamus and thereby inhibit the negative feedback of androgens on the hypothalamic–pituitary–gonadal axis (HPG axis).[83] This, in turn, results in increased gonadotropin secretion, activation of gonadal steroidogenesis, and an up to 2-fold increase in testosterone levels and 2.5-fold increase in estradiol levels.[84] Conversely, AR antagonists that are also progestogens, like cyproterone acetate, are not progonadotropic, as activation of the PR is antigonadotropic and preserves negative feedback on the HPG axis, and these medications are indeed potently antigonadotropic in clinical practice.[83]

Although spironolactone is an AR antagonist with no significant progestogenic effects in women even at high dosages and hence is a pure-like AR antagonist, many studies have not found it to be progonadotropic in men, nor to increase testosterone or estradiol levels.[29][85][86] Moreover, spironolactone is also said to possess very little or no antigonadotropic activity (in terms of lowering gonadotropin levels to below normal) even at high dosages,[5][87] although some conflicting reports exist.[88][89][90] Nonetheless, since spironolactone does not generally increase gonadotropin levels in spite of potent inhibition of androgen signaling, it must have some degree of antigonadotropic activity sufficient to at least keep the HPG axis from being upregulated.[83] As estrogens are antigonadotropic similarly to progestogens, and as SERM-like activity has been described for spironolactone, the antigonadotropic effects of spironolactone may be due to estrogenic activity.[6]

Glucocorticoid activity

Spironolactone weakly binds to and acts as an antagonist of the GR, showing antiglucocorticoid properties, but to a significant degree only at very high concentrations that are probably not clinically relevant.[76][91][92]

Most studies have found that spironolactone has no effect on cortisol levels.[8] However, some studies have observed increased cortisol levels with spironolactone treatment.[93][94] It is thought that this is due to the antimineralocorticoid activity of spironolactone, which prevents negative feedback of mineralocorticoids like aldosterone on the hypothalamic–pituitary–adrenal axis (HPA axis), and thereby upregulates adrenocorticotropic hormone (ACTH) and adrenal gland synthesis of corticosteroids such as cortisol and aldosterone.[93][94] Although spironolactone usually doesn't affect cortisol levels, it does significantly increase concentrations of aldosterone.[95]

Spironolactone has been shown to weakly inhibit 11β-hydroxylase in vitro.[23][96] This enzyme is responsible for the transformation of 11-deoxycorticosterone into corticosterone and of 11-deoxycortisol into cortisol.[5] The clinical significance of this action, if any, is unclear.[23][96][5] Spironolactone notably does not decrease cortisol or aldosterone levels.[8][95]

Other activities

Spironolactone is an agonist of the pregnane X receptor (PXR), a xenobiotic-sensing receptor.[13][97][12] By activating the PXR, spironolactone induces the expression of cytochrome P450 CYP3A enzymes and of the ATP-binding cassette transporter (ABC transporters) P-glycoprotein (multidrug resistance protein 1; MRP1; ABCB1) and multidrug resistance protein 2 (MRP2; ABCC2).[13][97][12][98][11][99][100][101][14] These proteins are involved in the metabolism and elimination of xenobiotics, and as a result, their induction by spironolactone may contribute to drug interactions of spironolactone.[13][97][12] Examples of such interactions include oral digoxin and estradiol.[99][53]

There is evidence that spironolactone may block voltage-dependent Ca2+ channels.[102][103]

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