Which adjustment is most appropriate for a patient with cirrhosis and ascites on spironolactone who remains symptomatic despite a low-sodium diet?

• A. Add furosemide 40 mg daily while continuing spironolactone
• B. Increase spironolactone to 200 mg daily
• C. Discontinue spironolactone and switch to furosemide alone
• D. Stop all diuretics

Answer: (A)

In cirrhosis with ascites, effective diuresis usually comes from using two diuretics with different mechanisms: an aldosterone blocker to counteract sodium retention and a loop diuretic to increase sodium excretion. Spironolactone addresses the hyperaldosteronism common in cirrhosis, reducing sodium and water retention while sparing potassium. If symptoms persist despite a low-sodium diet, adding a loop diuretic like furosemide provides additional natriuresis and helps overcome diuretic resistance by acting on another part of the kidney's sodium reabsorption pathways. Continuation of spironolactone preserves aldosterone blockade, and the combination can achieve better fluid removal than either drug alone. Monitor electrolytes and kidney function because spironolactone raises potassium while loop diuretics can cause potassium loss; adjust as needed.

Discontinuing spironolactone and using furosemide alone would remove the protective aldosterone blockade and could worsen potassium balance, while stopping all diuretics or using furosemide alone without spironolactone is less effective for ascites control in this setting. Increasing spironolactone alone might not provide the needed additional diuresis.