The Effects of a Reported Aldosterone Antagonist, Spirolactone, on Salivary

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1959 The effects of a reported aldosterone antagonist, spirolactone, on salivary and urinary electrolytes of patients with cirrhosis and ascites Marc David Schwartz Yale University

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The Effects of a Reported Aldosterone Antagonist,

Spirolactone, on Salivary and Urinary Electrolytes

of Patients with Cirrhosis and Ascites

Marc David Schwartz, B.A. 111 Princeton University 1955

A thesis submitted to the faculty of

The School of Medicine of Yale University

in partial fulfillment of the requirements

for the degree of Doctor of Medicine

Department of Internal Medicine

1959 'Y iz

O Om** ,

I would like to thank Dr. William A. Tisdale

and Dr. Gerald Klatskin for their counsel in the planning and carrying out of this thesis.

TABLE OP CONTENTS

Introduction . 1

Materials and Methods. 2

Results. i|

Discussion. 9

Summary and Conclusion.. .. 12

Tables. 13

Figures. 15

Bibliography. 19

INTRODUCTION

Aldosterone, the most potent of the mineralocorticolds secreted by the adrenal cortex, plays a prominent role in the regulation of water and electrolyte metabolism in normal and in certain pathological states. Since many features of its biological activity are as yet incompletely understood, the utilization of a compound capable of reversing or antagonizing its effect would provide a convenient investigative tool. In 1957 Kagawa et al.

( 1 ) reported that a synthetic steroidal spirolactone SC-5233 or its 19-nor analogue SC-8109 reversibly blocked the renal tubular effects of desoxycorticosterone acetate in adrenalectomized rats whereas neither of the spirolactones affected urinary electrolytes by itself. Recently Liddle ( 2 ) reported that SC-8109 reverses the renal tubular effects of aldosterone or biologically similar steroids such as DOCA in human subjects. In addition he reported that when patients with Addison’s disease were maintained on a high sodium diet without steroid therapy, the administration of spirolactone had little or no effect on urinary electrolytes.

These same patients maintained on a high sodium diet plus DOCA responded to spirolactone in a manner simulating the abrupt with¬ drawal of the renal effects of aldosterone. On the basis of these findings it has been suggested that spirolactone blocks the renal tubular effects of aldosterone.

The present investigation was designed to determine whether spirolactone’s effect of reducing aldosterone activity is limited to the kidney. J 2

MATERIALS AND METHODS

Sub jects

Three patients with Laennec Ts cirrhosis and intractible ascites were studied. In each case the diagnosis was histologically established by liver biopsy performed prior to the investigation.

One patient was studied on two occasions separated by a period of

8 months. To distinguish between these, they will be designated

AC-I and AC-II and will be considered separately in the text.

Pertinent clinical findings are recorded in Table 1. In each case the history revealed heavy alcholic intake and poor dietary habits. In all three patients previous treatment with bed rest, low sodium diet (10 mEq. per day), mercurial diuretics, and chlorthiazide had been ineffective in bringing about sodium and water loss. In addition RO had received a prior course of intra¬ venous albumin with no resultant change in weight. None had other significant illness or evidence of gastro-intestinal bleeding.

Program of study

Each subject was placed on a diet which included a daily intake of 10 mEq. of sodium, 23>00 calories, and from 60 to 80 grams of protein. Potassium intake was not regulated, but no potassium other than that contained in the diet was given. There was no restriction of fluid Intake.

Daily Z\\ hour urine specimens were collected under mineral oil with thymol crystals added as a preservative. The subjects were weighed at the same time each day. Urine volume was recorded and the samples analyzed for sodium, potassium, pH, ammonium, and titratable acidity.

Saliva specimens were obtained at the same time each day in

the following manner: after washing his mouth out with water, the

subject chewed a piece of paraffin, expectorating all saliva into

a sodium and potassium free container until 7 cc. were obtained.

Serum sodium, potassium, chloride, and bicarbonate concentrations were determined twice during the control period and at suitable

intervals throughout the study.

The subjects were observed carefully for any signs of drug

toxicity, including changes in vital signs, gastro-intestinal function, and mental status. The skin was examined for any changes, especially at the site of injection.

Blood samples from each subject were analyzed before and after

administration of the drug to detect any changes in hematocrit, white blood cell count, serum proteins, liver function tests,

and either blood urea nitrogen or non-protein nitrogen.

After a 3-d.ay control period each subject was given a 1-day

course of SC-8109 administered in 8 divided doses given every

3 hours. In studies in which more than 1 dosage range was used,

a subsequent dose was not administered until urinary excretion of

sodium had returned to the control level.

The dosages and routes of administration of the drug are

recorded in Table 2. AG became hyponatremic (serum sodium

z 120 mEq./liter) during the first study period following an

intramuscular dose of 800 mg. and was treated with 20 gms. of

NaCl by mouth and restriction of fluid intake over a period of

6 days at the end of the study (Fig. 1).

Me thod s

Urinary, salivary, and serum sodium and potassium were determined

on a Patwin flame photometer. Urinary ammonium was analyzed by the micro-diffusion method of Conway; titratable acidity by the method of

Henderson and Palmer (3)? and pH on a Cambridge electron ray pH meter. Serum chloride was determined by the method of Schales and

Schales (4) and bicarbonate by the method of Van Slyke and Neill (5)*

RESULTS

The results of the studies are illustrated in Figs. 1-4*

Effects on urinary sodium and potassium

On the day of administration of SC-8109 urinary sodium excretion

generally rose above the control levels of 1 to 5 mEq. per day and

then fell slowly to control levels. Two exceptions to this pattern were noted: in AC-II (Fig. 2) the rise continued for four days, at which time the study was discontinued; and in DS (Fig. 3) the 100 mg. dose had no demonstrable effect. The greatest 24 hour sodium excre¬

tion attained by the three subjects receiving the 800 mg. intramuscular dose was between 37 and 49 mEq. (Figs. 1, 3> and 4)«

In no subject was urinary potassium significantly increased by

the administration of SC-8109, and in AC-II there was a sizable decrease following drug administration. The rise in Na/K ratio

roughly paralleled sodium excretion, and in both studies of AC a

concomitant decrease in potassium excretion augmented the effect of

the increased sodium loss on the ratio.

Na/K ratios rose to a level between 4 and 6 times control values

after administration of the 800 mg. dose. The highest ratio reached,

1.3, was in the first study of AC following the administration of

400 mg. intramuscular dose. I,

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Effect on urinary hydrogen ion

AC-I and RO excreted decreased amounts of titratable acid

for 3 and 4 days respectively following the administration of SC-8109*

There was a concomitant small decrease in ammonium excretion in

RO and a rather large decrease for 1 day in AC. Urinary pH rose

in RO from a control level of about 6.0 to a level of 6.8 three

days after the administration of the drug, and in AC-I from 6.4

to 7.0 four days after administration.

The drug had no significant effect on urinary pH, titratable

acidity, or ammonium in DS. The increased urinary ammonium and

pH and decreased titratable acidity noted on day 6, three days

after DS received a 100 mg. parenteral dose of SC-8109, coincided o with an elevation of temperature to 101 P. The hydrogen ion

changes were attributed to a transient urinary tract infection,

but this was not definitely established.

Effect on urine volume

In general, parenterally administered SC-8109 had a much less

dramatic effect on urine volume than comparable doses given orally.

Parenteral administration of 800 mg. SC-8109 raised the urinary

volume by an average of 175 cc. for a period of 4 or 5 days. This

was in striking contrast to the effects of an 800 mg. oral dose,

which increased the urine volume by more than a liter a day for a

period of two days (see '’Comparison of dose and route”).

Effect on the saliva

Salivary sodium and potassium studies were carried out on all

3 subjects. A significant change occurred in one, and there was a

suggestive change in another. /

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Salivary Na/K ratios rose on the day of administration of all

doses to DS, the most significant rise occurring after the 800 mg.

oral dose when the ratio rose from 0.35 to 0.55* The changes in

ratio were usually due to both increased sodium and decreased potassium concentrations, but the 0.55 value was due to a significant decrease in potassium.

In the first study of AC, the salivary Na/K ratio rose to its highest level, O.36, the day after administration of [j_00 mg. intramuscular dose. There was no significant change after the

800 mg. dose, but at that time her serum sodium was depressed, and this may have affected the salivary sodium concentration.

Effect on Weight

In subjects AC-I and R0 there was a significant loss of weight within one or two days following the administration of

SC-8IO9. RO lost 0.7 kilos following a 800 mg. parenteral dose and AC-I lost 0.8 kilos following a 400 mg. dose by the same route.

Oral administration of 800 mg. to DS was followed by a leveling-off and slight reversal of a previously relentless weight increase.

Weight changes may have been obscured in some of the studies by the uncontrolled fluid intake.

Comparison of dose and route

Response to SC-8109 appeared to be affected by the size of the dose and the route of administration.

In general It was found that the greater the dose administered the greater the response. This was exemplified by the response of

DS, in terms of sodium excretion, to 100, ipOO, and 800 mg. parenteral •' ' •

* 7.

doses; no increase with the first, very small but significant in¬

crease with the second, and a relatively large increase with the

third (Pig. 3)«

Similarly AC-I had a greater response to I|.00 mg. than to

100 mg.jhowever there was no further increase in response to 800 mg.

This was most likely due to the decrease in serum sodium, the resultant decrease in filtered load of sodium causing a decrease in the amount delivered to the tubules. The subject may also have been secreting a greater quantity of aldosterone as a response to the lowering of the serum sodium.

Oral and parenteral dose responses can be compared in DS.

The oral dose resulted in a more abrupt rise and fall in urinary sodium excretion with a higher peak. Maximal effect was noted on the first day with the oral dose and on the second day with the intramuscular dose. The peak effect of an 800 mg. dose administered orally was a sodium excretion of 44 mEq. per day; that of 800 mg. given parenterally an excretion of 30 mEq. per day. Whereas it took only 3 days following the oral dose for urinary sodium excretion to return to control levels, it took 6 days following the parenteral dose. The total quantity of sodium lost after treatment by the two routes was approximately equal. More marked effects on salivary electrolytes occurred after 800 mg. given orally than after a comparable intramuscular dose.

Side effects

There was no change in vital signs or mental status in any of the subjects, and there was no significant change in blood urea nitrogen, non-protein nitrogen, serum proteins, or liver function tests * I

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No reaction or discomfort at the site of injection was encountered.

DS had a nose bleed on the day he received the I4.OO mg. intramuscular dose. Platelet counts done that day were over 3 200,000 per mm , and prothrombin time was 26% of normal. The prothrombin level during the control period was $5%. Fifty mg. of Vit. K-^ were given, and the prothrombin level rose above l±5%»

AC, in whom long-standing esophageal varices had been demonstrated by X-ray, had experienced intermittent gastro¬ intestinal disturbances for over a year prior to this investigation.

The second study of this subject was discontinued I4. days after administration of SC-8109 because of an exacerbation of those complaints, and the following day the patient bled from esophageal varices. In view of the antecedent complaints and the previous demonstration of varices, it is unlikely that these symptoms were due to the drug.

The hyponatremia encountered in AC was a disturbing complica¬ tion of treatment. Serum sodium fell in both studies; during the first period (Fig. 1) this was associated with a decrease in all other serum electrolytes; during the second period (Fig. 2) the other electrolytes were unaffected. In the first instance the hyponatremia was probably the result of urinary salt depletion complicated by serum dilution related to uncontrolled water intake.

Strict fluid restriction and an oral intake of 20 gms. of NaCl over a period of 6 days following the first study brought the serum sodium from a level of 120 mEq./liter back to the control level of

131 mEq./liter. Jo ’ll

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Patients with cirrhosis who are accumulating ascites have

been found to excrete in their urine only a small fraction of

the sodium they ingest. This avid sodium retention, manifested

not only in the urine but also in saliva, sweat, and feces, is

associated regularly with greatly elevated urinary levels of the

sodium-retaining hormone, aldosterone (7). Both of these findings

reflect, presumably, increased secretion and activity of the hormone.

Postulating that decreased activity of aldosterone might halt the fluid retention, Marson ( 8 ) and Guiseffi et al. ( 9 ) performed total adrenalectomies on patients with cirrhosis and

intractible ascites, achieving significant but incomplete diuresis

and sodium loss.

Amphenone, which inhibits the biogenesis of several adreno¬

cortical hormones including aldosterone, has been used to the same end (10). Its usefulness, however, is limited by its toxicity.

The synthetic steroidal spirolactone SC-8109 is reported to be active only in the presence of elevated levels of endogenous or exogenous aldosterone or biologically similar steriods, blocking their renal tubular actions competitively. In this study the effects of this compound on electrolyte and water metabolism in different end organ sites of aldosterone activity were investigated.

With both oral and parenteral administration of SC-8109 there was a marked increase in the urinary Na/K ratio. It Is evident that because of the small amounts of urinary sodium excreted during the control periods, an approximately equal increase in both sodium and potassium excretion would result in a significant increase in f >

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the Na/K ratio. This has been observed following the administration

of diuretics such as mercurials or carbonic anhydrase inhibitors ( 2 ).

More significant here is the fact that increased Na/K ratios occurred

in the absence of any increase in potassium excretion; there is a

suggestion that potassium excretion was actually decreased following

the administration of the compound in two of the subjects.

Two studies indicated that even at the time of maximal

sodium and water diuresis, hydrogen ion excretion, as measured by

urinary pH, ammonium, and titratable acidity, was decreased. There

was no observed effect on urinary hydrogen ion in one of the subjects.

Thus, there was increased sodium excretion and either decreased

or unchanged potassium excretion on all three subjects and decreased hydrogen ion excretion in two of these. Since the renal effect of

aldosterone is to decrease sodium excretion and to increase potassium and hydrogen ion excretion (1 ), the urinary electrolyte

findings reported here are consistent with the view that SC-8109

inhibits the activity of aldosterone in the kidney.

Aldosterone decreases sodium and/or increases potassium

concentration in saliva, sweat, and feces as well as in the urine (11). To test the hypothesis that the administration of

SC-8109 results in decreased aldosterone activity throughout the body, studies of salivary sodium and potassium were carried out.

Certain diuretics such as the mercurials raise the urinary Na/K

ratio but have no effect on the salivary electrolytes. In contrast,

SC-8IO9 caused a change in the salivary Na/K ratio in 2 of the 3

subjects studied which was consistent with a decrease in aldosterone

activity. • •,H

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Decreased aldosterone activity could be brought about in a

number of ways, including decreased secretion, increased urinary

losses and/or increased inactivation, as well as by competitive

inhibition. The exact mechanism of action of SC-8109 cannot be

determined from the data available at present. Certain inferences

can be made, however.

The fact that the compound is active in adrenalectomized

animals given desoxycorticosterone acetate or aldosterone indicates

that its mechanism is not primarily supression of secretion.

Indeed, Bolte et al. (12) found that in 2 patients with cirrhosis urinary excretion of aldosterone rose eight times above the control

level following, the administration of SC-8109, a finding presum¬

ably due to increased secretion. It is unlikely that spirolactone

acts by increasing losses of aldosterone in the urine, in view of

Leutcher’s findings that the compound blocked the action of aldosterone in a patient with nephrosis without changing urinary aldosterone. The relationship between aldosterone secretion and urinary excretion is somewhat obscured by the fact that urinary aldosterone as now measured by chromatographic methods represents

only 5 to 10% of the daily secretion (13).

The most probable action of spirolactone remains that of competitive inhibition at the end organ site of aldosterone activity.

However the remote possibility that it acts by increasing inactiva¬ tion of the hormone cannot be excluded.

The finding of this study suggest that SC-8109 may be of thera¬ peutic value in patients with cirrhosis and ascites. The compound has the advantage of inducing a sodium and water diuresis without any accompanying increase in potassium excretion. As with other I

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diuretics, hyponatremia must be considered a possible hazard. Whether

spirolactone is effective and free of toxic effects when given over

a long period remains to be seen.

SUMMARY AND CONCLUSIONS

Pour studies were carried out on cirrhotics with intract-

ible ascites, presumably associated with increased aldosterone

activity, to determine whether the synthetic steroidal

spirolactone SC-8109 reduces this activity in the kidney and

salivary glands.

The effects of the compound on urinary electrolytes were

consistent with a decreased aldosterone effect in the kidney in

all the subjects studied.

Its effects on salivary electrolytes were consistent with a

decreased aldosterone effect in one subject and suggestive of

this in another.

The reduction of aldosterone activity brought about by

SC-8109 thus is not limited to the renal tubule.

The most probable mechanism of action of SC-8IO9 is

competitive inhibition of aldosterone activity at its site of

action in the tissues.

The possible therapeutic value of SC-8109 remains to be determined. ‘J

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TABLE 1•

INITIAL CLINICAL AND LABORATORY FINDINGS

Patient DS AC-I AC-II RO

Age and sex 56 yr. M 69 yr. F 70 yr. F 67 yr. M

Ascites

Severity 4/ 2/ 3/ 3/

Duration 3 yr. 6 mo. 1 yr. 3 mo.

Pedal edema none none 1/ none

Serum Na (mEq/Liter) 139 133 llil 141

Serum K (mEq/liter) 4-5 4.7 44 4.5

Total protein (gm.%) 6.1 6.9 5*5 6.7

Alb./Glob. (gm.$) 2.7/34 2.1/4.8 1.6/3.9 2.9/3.8

Total bilirubin (mg.%) 1.32 1.26 1.28 1.38

Bromsulphalein retention (%) 3,0 o2% iW -- 32%

Blood urea N. (mg. %) 23 -- -- 25

Non-protein N. (mg. %) — 34 33 -- » f J

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TABLE 2.

DOSE A ED ROUTE OF ADMINISTRATION OF SC-8109

Intramuscular Oral

100 mg. 400 mg. 800 mg. 1|00 mg. 800 1

AC-I (Fig. 1) X X X

AC - II (Pig. 2) X

DS (Pig. 3) X X X X X

RO (Fig. 4) X ll I

. ' i . 1 •- ) 15.

PATIENT AC. (I) FIG. I.

0) tt D u 5

Li? UR i ME UJ e> \— $ X O ~ O £ * \ 2- _ c <\j fc X3 cr> O' I 36- 137- 28.8 14! 105 4.5 FIG. 2 273 105 4.3 |44 SC8I09 23! 104 4.5 !36 PATIENT A C (ID 16.

100 mg m iM 40G mgm IM 800mgrp IM 4o0fncm P0 BOOmgm V \ SC Si09 SC8109 SC8109

PATIENT DS F ! G. 3

800mgm IM SC8I09

2 3 4 5 6 7 8 9 .9 -|

.6 - o z . 3 -

+ cr o a> Z £

+ cr ^

xs __ o •tr cr aj o E .t: O'"

30 — + ^ cr X a> 2 0- z E I O —

CU '— £ £ 2 - 3 £ O ~ > — iS7777777yrm

o z _ 141 137 138 D V _l 45 4.2 4 4 a: _ cr O ^ 107 103 101 y <\l P o —• 26 25 23 0) o

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FIG. A PATIENT R O B

BIBLIOGRAPHY

Kawaga, G.M.; Celia, J.A., and Van Arman, C.G.: Action of

New Steroids in Blocking Effects of Aldosterone and

Dexoxycorticosterone on Salt, Science 126:1015, 1957

Liddle, G.W.: Aldosterone Antagonists, Arch. Int. Med. 102:995, 1958

Henderson, L.J. and Palmer, W.W.: On the Several Factors

of Acid Excretion, J. Biol. Chem. 17 005* 1914

Schales 0. and Schales S.S.: A Simple and Accurate Method for

the Determination of Chloride in Biological Fluids,

J. Biol. Chem. 140:879* 1941

Van Slyke, D.D., and Neill, J.M.: The Determination of Gases

in Blood and other Solutions by Vacuum Extraction and

Manometric Measurement I, J. Biol. Chem., 6l:523> 1924

Pawan, G.L.; Studies on the Salivary Na/K Rates in Man,

Biochem. J., 60:(Proc.)xii, 1955

Wolfe, H.P.; Koczorek, K.R., and Buckborn, E.: Aldosterone and

Antidiuretic Hormone in Liver Disease, Acta endocrinol.,

27:45, 1958

Marson, F.G.W.: Total Adrenalectomy in Hepatic Cirrhosis with

Ascites, Lancet 2:847* 1954

Guiseffi, J., Werk, E.E., Jr.: Larson, P.U.; Schiff, L., and

Elliot, D.W.: Effect of Bilateral Adrenalectomy in a

Patient with Massive Ascites and Postnecrotic Cirrhosis,

New England J. Med. 257:798* 1957 's j •

;) (10) Wolfe, S.: Past, B.; Stormont, J.M., and Davidson, C.S.:

Sodium Diuresis from Amphenone Given to Patients

with Cirrhosis and Ascites, New England J. Med. 257:215,

1957

(11) Eisenmenger, W.J.; Blondhein, S.H.; Bongiovanni, A.M.; Kunkel,H.G.

Electrolyte Studies on Patients with Cirrhosis of the Liver, J. Clin. Investig. 29:1491* 1950

(12) Bolte, E.; Verdy, M.; Marc-Aurele, J.; Erouillet, J.;

Beauregarde, P.; and Genest, J.: Studies on New Diuretic

Compounds: Spirolactone and Chlorthrazide, Canad. Med.

Assoc. J. 79:881, 1958

(13) Farrell, G.: Regulation of Aldosterone Excretion, Physiol.

Rev. 38:709, 1958 \

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