Table 7

Guidelines for Minimizing 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 exceeds 1.6 mg/dL.*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 exceeds 30 ml per minute is recommended.

  • 2. Aldosterone antagonists should not be administered to patients with baseline serum potassium in excess of 5.0 mEq per liter.

  • 3. An initial dose of spironolactone of 12.5 mg or eplerenone 25 mg is recommended, 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 ACEIs (captopril greater than or equal to 75 mg daily; enalapril or lisinopril greater than or equal to 10 mg daily.

  • 5. Non-steroidal anti-inflammatory drugs and cyclo-oxygenase-2 inhibitors should be avoided.

  • 6. Potassium supplements should be discontinued or reduced.

  • 7. Close monitoring of serum potassium is required; potassium levels and renal function should be checked in 3 days and at 1 week after initiating therapy and at least monthly for the first 3 months.

  • 8. Diarrhea or other causes of dehydration should be addressed emergently.

ACEI indicates angiotensin converting enzyme inhibitor.

  • * Although the entry criteria for the trials of aldosterone antagonists included creatinine greater than 2.5 mg per dL, the majority of patients had creatinine much lower; in 1 trial (335a) 95% of patients had creatinine less than or equal to 1.7 mg per dL.