Treatment
Table 15. Strategies to Minimize the Risk of Hyperkalemia
in Patients Treated With Aldosterone Antagonists
1.
Impaired renal function is a risk factor for hyperkalemia during treatment with
aldosterone antagonists. The risk of hyperkalemia increases progressively when
serum creatinine is >1.6 mg/dL.a In elderly patients or others with low muscle mass
in whom serum creatinine does not accurately reflect glomerular filtration rate,
determination that glomerular filtration rate or creatinine clearance is
>30 mL/min/1.73 m2 is recommended.
2.
Aldosterone antagonists would not ordinarily be initiated in patients with baseline
serum potassium >5.0 mEq/L.
3.
An initial dose of spironolactone of 12.5 mg or eplerenone 25 mg is typical,
following which the dose may be increased to spironolactone 25 mg or eplerenone
50 mg, if appropriate.
4.
The risk of hyperkalemia is increased with concomitant use of higher doses of
ACE inhibitors (captopril ≥75 mg daily; enalapril or lisinopril ≥10 mg daily).
5.
In most circumstances potassium supplements are discontinued or reduced when
initiating aldosterone antagonists.
6.
Close monitoring of serum potassium is required; potassium levels and renal
function are most typically checked in 3 days and at 1 week after initiating therapy
and at least monthly for the first 3 months.
a
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Although the entry criteria for the trials of aldosterone antagonists included creatinine <2.5 mg/dL,
the majority of patients had much lower creatinine; in 1 trial, 95% of patients had creatinine
≤1.7 mg/dL.
