Eplerenone Use in Patients with Severe Renal Impairment

Introduction to Contraindication

Eplerenone is contraindicated in patients with a GFR less than 30 ml/min due to high risk of life-threatening hyperkalemia 1, 2

Mineralocorticoid receptor antagonists (MRAs) like eplerenone significantly increase the risk of hyperkalemia in patients with severely impaired renal function 1, 3
The American Heart Association/American College of Cardiology guidelines explicitly recommend MRAs only if estimated glomerular filtration rate is >30 mL/min/1.73 m² and serum potassium is <5.0 mEq/L 1

For patients with heart failure and GFR <30 ml/min, other evidence-based therapies should be prioritized, including SGLT2 inhibitors, which have proven mortality benefits in heart failure regardless of the presence of diabetes 1
Beta-blockers with proven mortality benefits (bisoprolol, carvedilol, sustained-release metoprolol succinate) should be continued as they do not have renal clearance restrictions 1
Loop diuretics can be used for volume management in patients with severe renal impairment 4
If potassium levels are normal and the patient has heart failure with reduced ejection fraction, ACE inhibitors or ARBs should be continued with close monitoring 1, 3

If a clinical decision is made to use eplerenone despite severe renal impairment, check potassium and renal function within 2-3 days of initiation, and then regularly 4, 2
Discontinue eplerenone immediately if potassium rises above 6.0 mmol/L 4, 2
Avoid concomitant use of NSAIDs, potassium supplements, and high-potassium foods 2
Temporarily stop eplerenone during episodes of diarrhea, dehydration, or when loop diuretic therapy is interrupted 2