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CARDIOLOGY

Laboratory Evaluation of Potassium and Creatinine Among Ambulatory Patients Prescribed Spironolactone: Are We Monitoring for Hyperkalemia?

Pharmacotherapy Research Manager and Associate Clinical Professor, Kaiser Permanente Colorado Clinical Research Unit and School of Pharmacy, University of Colorado at Denver and Health Sciences Center, Denver, CO

David L McClure, PhD

Epidemiologist, Kaiser Permanente Colorado Clinical Research Unit, Denver

K Arnold Chan, MD ScD

Investigator and Assistant Professor, I3Magnify Epidemiology and Harvard Medical School, Boston, MA

Steven R Simon, MD MPH

Assistant Professor, Harvard Medical School and Harvard Pilgrim Health Care, Boston

Adrianne C Feldstein, MD MS

Investigator, Kaiser Permanente Northwest Center for Health Research and Oregon Health Sciences University, Portland, OR

Jennifer Elston Lafata, PhD

Research Scientist, Center for Health Services Research, Henry Ford Health System, Detroit, MI

Susan E Andrade, ScD

Assistant Professor of Medicine, Meyers Primary Care Institute, Fallon Foundation, and University of Massachusetts Medical School, Worcester, MA

Margaret J Gunter, PhD

President and Executive Director, Lovelace Clinic Foundation, Albuquerque, NM

Winnie W Nelson, PharmD MS

at time of study, HealthPartners Research Foundation, Minneapolis, MN; now, Consultant, Applied Health Outcomes, Palm Harbor, FL

Douglas Roblin, PhD

Research Scientist, Kaiser Permanente Southeast, Atlanta, GA

Richard Platt, MD MS

Professor and Chair, Ambulatory Care and Prevention, Medicine, Harvard Medical School, Harvard Pilgrim Health Care, Channing Laboratory, Brigham and Women's Hospital, Boston

Reprints: Dr. Raebel, Kaiser Permanente Colorado, Clinical Research Unit, PO Box 378066, Denver, CO 80237, fax 303/614-1265, Marsha.A.Raebel{at}kp.org

BACKGROUND: Serum potassium and creatinine evaluation is recommended in patients prescribed spironolactone, yet the proportion of ambulatory patients chronically dispensed spironolactone receiving evaluation is not well understood.

OBJECTIVE: To estimate the rate of potassium and creatinine evaluation and identify factors associated with conducting these tests among ambulatory patients dispensed spironolactone.

METHODS: A retrospective cohort study was designed to evaluate patients at 10 health maintenance organizations with ongoing spironolactone dispensing for one year (N = 2257). Potassium and creatinine evaluation were determined from administrative data. Associations between patient characteristics and laboratory testing were assessed, using logistic regression modeling.

RESULTS: Serum creatinine and potassium were evaluated in 72.3% of patients during a 13 month period. The likelihood of potassium and creatinine monitoring was greater among patients who were older (OR 1.28; 95% CI 1.17 to 1.41 per decade of life); male (OR 1.25; 95% CI 1.01 to 1.54); had diabetes (OR 1.63; 95% CI 1.31 to 2.03); received concomitant therapy with angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (OR 2.23; 95% CI 1.74 to 2.87), potassium supplements (OR 1.96; 95% CI 1.51 to 2.54), or digoxin (OR 2.10 95% CI 1.48 to 2.98); or had more outpatient visits (OR 1.31; 95% CI 1.19 to 1.44). Among patients with heart failure (n = 790), factors associated with the incidence of laboratory testing were diabetes (OR 1.64, 95% CI 1.14 to 2.34), outpatient visits (OR 1.20; 95% CI 1.02 to 1.41), and digoxin therapy (OR 2.26; 95% CI 1.38 to 3.69).

CONCLUSIONS: Three-fourths of ambulatory patients dispensed spironolactone receive recommended laboratory evaluation, with monitoring more likely to be completed in patients prescribed concomitant therapy with drugs that increase hyperkalemia risk, older patients, and those with diabetes.

Key Words: potassium, serum creatinine, spironolactone

Published Online, February 6, 2007. www.theannals.com, DOI 10.1345/aph.1H520

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