Eplerenone monitoring

Before starting

Required

• Baseline
  • Estimated glomerular filtration rate or Serum creatinine (for creatinine clearance) · contraindicated if eGFR less than 30mL/min/1.73m²; reduce starting dose to 25 mg on alternate days if eGFR 30 to 60 mL/minute/1.73 m²
  • Electrolytes
  • Serum potassium · contraindicated if over 5.0 mmol/L

After started or dose changed

Required

• After 1 week; then monthly for first 3 months
  • Serum creatinine (for creatinine clearance) or Estimated glomerular filtration rate
  • Electrolytes
  • Serum potassium · refer to abnormal results section for management of abnormal serum potassium
• Before and after each dose increase
  • Blood pressure

Ongoing once stable

Required

• Every 6 months
  • Serum creatinine (for creatinine clearance) or Estimated glomerular filtration rate
  • Electrolytes
  • Serum potassium · refer to abnormal results section for management of abnormal serum potassium

Abnormal results

Renal function

• Stop if eGFR less than 30mL/min/1.73m²
• Reduce dose and monitor serum potassium if eGFR 30 – 60mL/min/1.73m²

Adjusting doses to serum potassium

After initiation, adjust dose based on the potassium level.

Level lower than 5.0 mmol/L

• If dose normally 25mg every other day, increase to 25mg daily
• If dose normally 25mg daily, increase to 50mg daily

Level between 5.0 mmol/L and 5.4 mmol/L

• No dose adjustment required

Level between 5.5 mmol/L and 5.9 mmol/L

• If dose normally 25mg every other day, then withhold
• If dose normally 25mg daily, reduce to 25mg every other day
• If dose normally 50mg daily, reduce to 25mg daily

Level greater than 6.0mmol/L

• Withhold

Hepatic impairment

Mild to moderate hepatic impairment present (Child-Pugh Class A and B)

• Monitor serum potassium and other electrolytes regularly

Severe hepatic impairment present (Child-Pugh Class C)

• Stop eplerenone

Notes

Estimating renal function

Use creatinine clearance (calculated from the Cockroft-Gault equation) instead of eGFR to calculate dose adjustments in patients who are:

• over 75 years
• at extremes of muscle mass (BMI less than 18kg/m2 or greater than 40 kg/m2)

Advice to patients

Advise patients to:

• avoid NSAIDs unless prescribed
• avoid salt substitutes containing potassium
• contact prescriber if diarrhoea, vomiting, or infection with fever and sweating occurs

Bibliography

• British National Formulary (online) London: BMJ Group and Pharmaceutical Press [cited 09/08/2025]
• Upjohn UK Limited. Summary of Product Characteristics – Inspra 25mg film-coated tablets. Last updated 17/01/2028 [cited 09/08/2025]
• McDonagh T A, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure. of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. European Heart Journal, Volume 22, Issue 36, 21 Sep 2021, Pages 3599-3726 [cited 09/08/2025]
• McDonagh T A, Marco M, Marianna A, et al., ESC Scientific Document Group , 2023 Focused Update of the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC, European Heart Journal, Volume 44, Issue 37, 1 October 2023, Pages 3627 – 3639, https://doi.org/10.1093/eurheartj/ehad195
• National Institute for Health and Care Excellence (NICE). Acute coronary syndromes NG 185. Nov 2020 [cited 09/08/2025]
• National Institute for Health and Care Excellence (NICE). Chronic heart failure in adults: diagnosis and management [NG 106]. Sep 2018 [cited 09/08/2025]
• Scottish Intercollegiate Guidelines Network (SIGN). Management of chronic heart failure (Guideline 147). March 2016 revalidated 2019. [cited 09/08/2025]

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