When starting eplerenone, should frusemide be stopped or its dose reduced?

Management of Furosemide When Starting Eplerenone

When starting eplerenone therapy, furosemide dose should be reduced rather than stopped completely, with careful monitoring of renal function and electrolytes to avoid hyperkalemia and renal dysfunction. 1

Initial Assessment Before Starting Eplerenone

• Check baseline renal function and serum electrolytes before initiating eplerenone 1
• Ensure potassium is ≤5.0 mmol/L and creatinine is <220 μmol/L (2.5 mg/dL) in men or <2.0 mg/dL in women 1
• Verify estimated glomerular filtration rate (eGFR) is >30 mL/min/1.73 m² 1, 2

Furosemide Adjustment Protocol

• Reduce furosemide dose by approximately 25-50% when initiating eplerenone to minimize risk of dehydration and electrolyte disturbances 1, 3
• For patients at higher risk of hyperkalemia (elderly, diabetics, eGFR <60 mL/min/1.73 m²), consider a more significant reduction in furosemide dose 1, 4
• Do not completely discontinue furosemide if the patient has significant fluid retention or a history of heart failure decompensation 1, 5

Eplerenone Initiation

• Start eplerenone at 25 mg once daily (or 25 mg every other day if eGFR 30-49 mL/min/1.73 m²) 1, 2
• Discontinue potassium supplements when starting eplerenone, as it has potassium-sparing effects 1
• Counsel patients to avoid foods high in potassium and NSAIDs 1

Monitoring Protocol

• Check renal function and serum electrolytes within 2-3 days after starting eplerenone 1
• Recheck at 1 week after initiation 1
• Further monitoring at 4 weeks and then monthly for the first 3 months 1, 2
• Adjust furosemide dose based on:
  • Clinical status (signs of congestion or dehydration) 1, 6
  • Renal function and electrolyte levels 1
  • Blood pressure response 7

Management of Complications

• If potassium rises to >5.5 mmol/L, halve eplerenone dose (to 25 mg on alternate days) and consider increasing furosemide dose 1
• If potassium rises to ≥6.0 mmol/L, stop eplerenone immediately and increase furosemide dose 1
• If creatinine rises to >220 μmol/L (2.5 mg/dL), reduce eplerenone dose and adjust furosemide as needed 1
• If creatinine rises to >310 μmol/L (3.5 mg/dL), stop eplerenone immediately 1

Dose Titration

• Consider eplerenone dose up-titration after 4-8 weeks if potassium and renal function remain stable 1
• Target dose is 50 mg once daily 1, 2
• Adjust furosemide dose as needed based on volume status and electrolyte levels 1

Common Pitfalls to Avoid

• Failure to reduce furosemide dose when starting eplerenone may lead to dehydration and prerenal azotemia 3, 6
• Complete discontinuation of furosemide may lead to fluid retention in patients who require diuresis 5, 6
• Inadequate monitoring of electrolytes and renal function can lead to dangerous hyperkalemia 1, 4
• Not considering patient-specific risk factors for hyperkalemia (diabetes, elderly, reduced renal function) 4