Is it safe to continue Eplerenone therapy in a patient with normal potassium levels, mildly impaired renal function, left ventricular ejection fraction of 55-60%, very low microalbumin levels, and mild sleep apnea, without a diagnosis of primary aldosteronism?

Eplerenone Should Be Discontinued in Your Clinical Scenario

You do not meet the established criteria for mineralocorticoid receptor antagonist (MRA) therapy and should discontinue eplerenone 25 mg. Your preserved ejection fraction (55-60%), absence of heart failure symptoms, very low albuminuria, and lack of confirmed aldosteronism provide no evidence-based indication for this medication, while your mildly reduced eGFR (64 mL/min/1.73 m²) increases your hyperkalemia risk without corresponding benefit.

Why Eplerenone Is Not Indicated in Your Case

Heart Failure Indications Do Not Apply

• ACC/AHA guidelines recommend aldosterone receptor antagonists only for patients with LVEF ≤35-40% and symptomatic heart failure (NYHA class II-IV) 1
• Your EF of 55-60% represents preserved systolic function, placing you far outside the evidence-based range for MRA therapy 1
• The landmark trials (RALES, EMPHASIS-HF, EPHESUS) that established MRA benefits exclusively enrolled patients with reduced ejection fraction and heart failure symptoms 1, 2
• No mortality or morbidity benefit has been demonstrated for MRAs in patients with preserved ejection fraction 1

Diabetic Kidney Disease Indications Do Not Apply

• The 2022 ADA/KDIGO consensus recommends non-steroidal MRAs (specifically finerenone) only for patients with type 2 diabetes AND albuminuria (ACR ≥30 mg/g) 1
• Your uACR is not calculable due to very low microalbumin levels, indicating you lack the albuminuria required for MRA consideration in diabetic kidney disease 1
• Even if you had diabetes, finerenone (not eplerenone) is the recommended agent, and only with documented albuminuria despite maximal RAS inhibition 1

Primary Aldosteronism Has Not Been Confirmed

• You explicitly state aldosteronism has not been measured, eliminating the only other potential indication for eplerenone therapy 3
• Without confirmed primary aldosteronism through appropriate testing (aldosterone-renin ratio, confirmatory testing), empiric MRA therapy lacks justification 3

Significant Safety Concerns in Your Case

Renal Function Creates Elevated Risk

• Your eGFR of 64 mL/min/1.73 m² places you in the moderate renal impairment category where hyperkalemia risk substantially increases 1, 2
• ACC/AHA guidelines specify that patients with eGFR <60 mL/min/1.73 m² require reduced initial dosing (eplerenone 25 mg) due to elevated hyperkalemia risk 1
• In the EMPHASIS-HF trial, patients with eGFR <60 mL/min/1.73 m² had hyperkalemia rates of 10.1% on eplerenone versus 4.6% on placebo 1, 2
• The FDA label for eplerenone explicitly warns that impaired renal function increases hyperkalemia risk and requires careful monitoring 4

No Offsetting Benefit to Justify Risk

• The risk-benefit calculation for MRAs depends on substantial mortality/morbidity reduction in heart failure patients 1
• Without heart failure or significant albuminuria, you face the hyperkalemia risk without any demonstrated benefit to mortality, hospitalization, or quality of life 1, 2
• Population-based studies showed that inappropriate MRA use increased hyperkalemia hospitalizations from 2.4 to 11 per thousand patients, with mortality increasing from 0.3 to 2 per thousand 1

Monitoring Burden Without Clinical Indication

• ACC/AHA guidelines require potassium and creatinine monitoring at 3 days, 1 week, monthly for 3 months, then every 3 months during MRA therapy 1, 5
• This intensive monitoring burden is justified when treating life-threatening conditions like heart failure, but not for off-label use without established indication 5, 6

Common Pitfall: Prescribing MRAs for Hypertension Alone

• While eplerenone has antihypertensive effects, it is not recommended as a primary antihypertensive agent in patients without heart failure, post-MI LV dysfunction, or confirmed primary aldosteronism 7, 3
• Your blood pressure is described as normotensive (except possibly nocturnal elevation from mild sleep apnea), which does not constitute an indication for MRA therapy 3
• If nocturnal hypertension is confirmed by ABPM, addressing the underlying sleep apnea with CPAP therapy would be the appropriate first-line intervention 3

Recommended Action Plan

Discontinue Eplerenone

• Stop eplerenone 25 mg immediately, as you lack any evidence-based indication for this medication 1, 5
• Your current potassium of 4.3 mmol/L is acceptable, but continuing eplerenone without indication exposes you to unnecessary hyperkalemia risk as renal function may fluctuate 5, 4

Address the Actual Clinical Issues

• Complete the ABPM study to objectively assess nocturnal blood pressure and determine if treatment is needed 3
• If nocturnal hypertension is confirmed, optimize sleep apnea management first (CPAP therapy if indicated) 3
• If additional antihypertensive therapy becomes necessary, use evidence-based first-line agents (ACE inhibitors, ARBs, thiazides, or calcium channel blockers) rather than MRAs 1, 3

Monitor Renal Function

• With eGFR 64 mL/min/1.73 m², periodic monitoring of kidney function is appropriate regardless of medication changes 1
• If you have diabetes, annual uACR screening should continue to detect development of albuminuria 1

Why Your Trepidation Is Justified

Your instinct to be concerned about taking eplerenone is medically sound. The medication carries real risks (hyperkalemia, worsening renal function) without providing you any demonstrated benefit in mortality, morbidity, or quality of life 1, 4, 2. The evidence supporting MRA therapy is robust but specific to patients with reduced ejection fraction heart failure or diabetic kidney disease with albuminuria—neither of which applies to your situation 1.