From the Guidelines
Alternatives to spironolactone for heart failure include eplerenone, which is another mineralocorticoid receptor antagonist with fewer hormonal side effects than spironolactone, and is typically dosed at 25-50 mg once daily 1. Eplerenone is particularly useful for patients who experience gynecomastia, breast tenderness, or sexual dysfunction with spironolactone. Other potassium-sparing diuretics like amiloride (5-10 mg daily) or triamterene (50-100 mg daily) can be considered, though they have less evidence for mortality benefit in heart failure. Some key points to consider when choosing an alternative to spironolactone include:
- The patient's specific situation, including kidney function, potassium levels, blood pressure, and tolerance of side effects
- The use of ACE inhibitors (like enalapril 2.5-20 mg twice daily or lisinopril 5-40 mg daily) and ARBs (such as valsartan 40-160 mg twice daily or losartan 25-100 mg daily), which modulate the renin-angiotensin system and have proven benefits in heart failure 1
- The use of the newer SGLT2 inhibitors (dapagliflozin 10 mg daily or empagliflozin 10 mg daily), which promote glucose excretion and have additional cardioprotective effects 1
- The potential for hyperkalemia and worsening renal function with the use of mineralocorticoid receptor antagonists, and the need for careful monitoring of patients with impaired renal function 1
- The importance of individualizing treatment and considering the patient's specific needs and circumstances when selecting an alternative to spironolactone. It is also important to note that the choice among these alternatives should be based on the most recent and highest quality evidence, and that the patient's specific situation and needs should be taken into account when making a decision 1.
From the Research
Alternatives to Spironolactone for Treating Heart Failure
- Finerenone: a novel nonsteroidal mineralocorticoid receptor antagonist with higher selectivity toward the mineralocorticoid receptor compared to spironolactone, and stronger MR-binding affinity than eplerenone 2
- Eplerenone: a steroidal mineralocorticoid receptor antagonist that has been used to treat patients with heart failure, and has been shown to be beneficial in patients with heart failure with reduced ejection fraction (HFrEF) 3, 4, 5
Comparison of Alternatives
- Finerenone has been shown to be equivalent to spironolactone in terms of anti-ventricular remodeling, and may have a lower incidence of treatment-related adverse events and hyperkalemia 6
- Eplerenone has been compared to spironolactone in a nationwide cohort study, and was found to have no differences in clinical outcomes, but had a lower treatment withdrawal rate and higher daily dose 5