What is the recommended dose of Eplerenone (mineralocorticoid receptor antagonist)?

Recommended Dosage of Eplerenone

The standard recommended dosage of eplerenone for most indications is 25 mg once daily initially, titrated to 50 mg once daily as the target maintenance dose, with dose adjustments based on serum potassium levels and renal function. 1

Dosing Regimens by Indication

Heart Failure

• Initial dose: 25 mg once daily 1, 2
• Target maintenance dose: 50 mg once daily, preferably titrated within 4 weeks as tolerated 1, 3
• Dose adjustments based on serum potassium levels (see monitoring section below) 1

Hypertension

• Initial dose: 50 mg once daily 1
• For inadequate blood pressure response: May increase to 50 mg twice daily (100 mg total daily dose) 1, 4
• Full therapeutic effect typically apparent within 4 weeks 1
• Doses above 100 mg daily are not recommended as they provide no additional blood pressure reduction but increase hyperkalemia risk 1, 4

Central Serous Chorioretinopathy (Off-label use)

• Most common regimen: 25 mg daily for 1 week, then 50 mg daily thereafter 5
• Treatment duration varies from 1-12 months depending on clinical response 5
• Some protocols maintain 25 mg daily or use 50 mg daily from initiation 5

Dose Modifications

Renal Impairment

• For eGFR 30-49 mL/min/1.73 m²: Maximum 25 mg once daily 6
• For eGFR <30 mL/min/1.73 m²: Use is not recommended 6
• Studies show 25 mg daily in patients with eGFR 30-49 mL/min/1.73 m² is as effective as 50 mg daily in those with better renal function, though adverse events are more common 6

Drug Interactions

• When used with moderate CYP3A inhibitors (e.g., erythromycin, verapamil, fluconazole):
  • For heart failure patients: Do not exceed 25 mg once daily 1
  • For hypertension patients: Start at 25 mg once daily, may increase to maximum of 25 mg twice daily if needed 1

Monitoring Requirements

• Check serum potassium before initiating therapy 1, 7
• Recheck within the first week of treatment 1
• Check again at one month after starting treatment or dose adjustment 1
• Assess periodically thereafter 1
• Additional monitoring within 3-7 days when starting concurrent medications that may affect potassium levels (ACE inhibitors, ARBs, NSAIDs) 1

Dose Adjustment Based on Serum Potassium

• If K⁺ <5.0 mEq/L: May increase dose from 25 mg every other day to 25 mg daily, or from 25 mg daily to 50 mg daily 1
• If K⁺ 5.0-5.4 mEq/L: No adjustment needed 1
• If K⁺ 5.5-5.9 mEq/L: Reduce dose (50 mg daily to 25 mg daily, or 25 mg daily to 25 mg every other day) 1
• If K⁺ ≥6.0 mEq/L: Withhold medication and restart at 25 mg every other day when K⁺ <5.5 mEq/L 1

Common Pitfalls and Caveats

• Hyperkalemia is the most common and potentially dangerous side effect, requiring careful monitoring 7
• Unlike spironolactone, eplerenone has greater mineralocorticoid receptor selectivity, resulting in fewer hormonal side effects like gynecomastia 7
• Dose response effect for blood pressure appears to plateau at 50-200 mg daily, with no additional benefit at higher doses 4
• Concurrent use of potassium supplements or potassium-sparing diuretics should be avoided or carefully monitored 1, 7
• Patients with impaired renal function experience more adverse events despite receiving lower eplerenone doses 6