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Selective Mineralocorticoid Receptor Antagonist Pregnancy: No adequate data in pregnant women; caution should be exercised when prescribing in pregnancy. Breast-feeding: decision to discontinue nursing or the drug should weigh its importance to the mother.

Eplerenone

Brand names: Inspra

Used in: Heart Failure

Eplerenone is a selective mineralocorticoid-receptor antagonist used in heart failure after myocardial infarction and in chronic heart failure with reduced ejection fraction.

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: 25 mg once daily initially, titrated to target 50 mg once daily
Route: Oral
Frequency: Once daily (with or without food)
Max: 50 mg daily
Post-MI heart failure: initiate at 25 mg once daily and titrate to target 50 mg once daily preferably within 4 weeks, guided by serum potassium; therapy usually started 3-14 days after acute MI. Chronic NYHA class II heart failure: initiate 25 mg once daily, titrate to 50 mg once daily within 4 weeks. Do not start if serum potassium >5.0 mmol/L. Measure serum potassium before initiation, within the first week, at one month, and periodically; adjust dose per the SPC potassium table (25 mg every other day / 25 mg OD / 50 mg OD; decrease or withhold if potassium rises). With mild-to-moderate CYP3A4 inhibitors (amiodarone, diltiazem, verapamil) do not exceed 25 mg once daily.

Dose adjustments

Renal

Mild impairment: no initial adjustment (monitor potassium). Moderate impairment (CrCl 30-60 mL/min): start 25 mg every other day. Severe impairment (CrCl/eGFR <30): contraindicated. Eplerenone is not dialysable.

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

US labelling (FDA)

Reference — US labelling, may differ from UK

HFrEF Post-MI: Initiate treatment with 25 mg once daily. Titrate to maximum of 50 mg once daily within 4 weeks, as tolerated. Dose adjustments may be required based on potassium levels. ( 2.1 ) Hypertension: 50 mg once daily, alone or combined with other antihypertensive agents. For inadequate response, increase to 50 mg twice daily. Higher dosages are not recommended. ( 2.2 ) For all patients: Measure serum potassium before starting INSPRA and periodically thereafter. ( 2.3 ) 2.1 Heart Failure Post-Myocardial Infarction Initiate treatment at 25 mg once daily and titrate to the recommended dose of 50 mg once daily, preferably within 4 weeks as tolerated by the patient. Once treatment with …

Source: US FDA prescribing information (openFDA / DailyMed), label dated 2025-06-23. Accessed 2026-06-12. US dosing and indications can differ from UK practice — use UK sources for prescribing decisions.

Contraindications

  • Hypersensitivity to the active substance or excipients
  • Serum potassium >5.0 mmol/L at initiation
  • Severe renal insufficiency (eGFR <30 mL/min/1.73 m2)
  • Severe hepatic insufficiency (Child-Pugh class C)
  • Concomitant potassium-sparing diuretics or strong CYP3A4 inhibitors (itraconazole, ketoconazole, ritonavir, nelfinavir, clarithromycin, telithromycin, nefazodone)
  • Combination of an ACE inhibitor and an ARB together with eplerenone

Side effects

  • Hyperkalaemia
  • Dizziness, headache
  • Hypotension
  • Diarrhoea, nausea
  • Renal impairment

Interactions

  • Strong CYP3A4 inhibitors - contraindicated; mild-to-moderate CYP3A4 inhibitors (amiodarone, diltiazem, verapamil) - limit to 25 mg once daily
  • Potassium-sparing diuretics and potassium supplements - increased risk of hyperkalaemia
  • ACE inhibitors and/or ARBs - increased hyperkalaemia risk (ACE inhibitor + ARB + eplerenone combination should not be used)
  • Strong CYP3A4 inducers - not recommended; lithium, ciclosporin, tacrolimus - avoid

Clinical monograph

How it works

It selectively blocks the mineralocorticoid (aldosterone) receptor, reducing adverse cardiac remodelling and promoting modest sodium loss with potassium retention.

Prescribing in practice

  • Hyperkalaemia is the key risk — check renal function and potassium before and after starting or up-titrating, and avoid in significant renal impairment or pre-existing hyperkalaemia.
  • It is more selective than spironolactone, so it causes less gynaecomastia.
  • Risk rises with ACE inhibitors/ARBs, potassium supplements and strong CYP3A4 inhibitors.

Monitoring

Monitor potassium and renal function at baseline, after initiation/titration, and periodically.

Counselling the patient

  • Avoid potassium-based salt substitutes and over-the-counter potassium.
  • Report marked tiredness or palpitations.

Evidence & guidelines

Improves outcomes in post-MI heart failure and HFrEF (e.g. EPHESUS, EMPHASIS-HF); part of guideline-directed therapy (NICE NG106).

Reference: EPHESUS (Pitt et al, NEJM 2003); EMPHASIS-HF (Zannad et al, NEJM 2011); Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Related

Curated clinical cross-links plus same-class fallbacks.

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