Table 4

Guidance on when, where and how to use MRAs in heart failure and guidance on ‘troubleshooting’ common issues

When to useAs a third agent in those already on maximal tolerated dose of ACE inhibitors and a β-blocker in all patients with systolic heart failure NYHA class II–IV.
When not to useHyperkalaemia, Addison's disease.
CautionsSignificant renal dysfunction creatinine >221 µmol/L or significant hyperkalaemia K+ >5.0 mmol/L. Drug interactions such as NSAIDs, other nephrotoxic drugs and low-salt preparations containing a high potassium load.
How to use‘Start low and go slow’. Check blood chemistry at 1, 4, 8 and 12 weeks; 6, 9 and 12 months, 6 monthly thereafter.
CounsellingExplain expected benefits, symptom improvement occurs in weeks to months. Advise on the use of over-the-counter medications (NSAIDs). Temporarily stop spironolactone and contact your doctor if diarrhoea and/or vomiting develop.
TroubleshootingHyperkalaemia and renal dysfunction
If K+ rises between 5.5 and 6.0 mmol/L or creatinine rises to >221 µmol/L, reduce dose and monitor blood chemistry closely.
If K+ rises to >6.0 mmol/L or creatinine to >354 µmol/L, stop the drug and seek specialist advice.
  • Adapted from McMurray et al and the British National Formulary.17 ,18

  • MRA, mineralocorticoid receptor antagonists; NSAIDs, non-steroidal anti-inflammatory drugs; NYHA, New York Heart Association.