Aldosterone antagonists contraindications

In patients without contraindications, spironolactone is initiated at a dose of 12.5 to 25 mg daily, or occasionally on alternate days for patients with baseline renal insufficiency. Eplerenone is used at a dose of 25 mg daily, with the option to titrate up to 50 mg daily. Doses should be halved or switched to alternate-day dosing if creatinine clearance falls below 50 mL/minute. Potassium supplementation is often decreased or stopped after aldosterone antagonists are initiated, and patients should be counseled to avoid high-potassium foods. At anytime after initiation of therapy, if potassium concentrations exceed... 

Symptomatic or prior-symptomatic fluid retention responds well to treatment with diuretics and salt restriction if LVEF is reduced. This will usually improve current HF symptoms. Especially, an aldosterone antagonist like spironolactone should be added in selected patients with advanced HF symptoms and reduced LVEF with preserved renal function. Potassium has to be normal and should be carefully monitored. Patients with renal dysfunction and with serum creatinine levels >2.5 mg/dl in men and >2.0 mg/dl in women are contraindicated for aldosterone antagonists. 

ACE-I is recommended for all the patients in this stage unless contra-indicated. If contraindications for ACE-I exist an ARB can be given. However, the routine combination of ACE-I, ARB and aldosterone antagonists is not to be recommended. 

ACE inhibitors are absolutely contraindicated in pregnancy (see Pregnancy section under Special Populations ) and in patients with a history of angioedema. Similar to diuretics, ACE inhibitors can increase lithium serum concentrations in patients on lithium therapy. Concurrent use of an ACE inhibitor with a potassium-sparing diuretic (including aldosterone antagonists), potassium supplements, or an ARB may result in excessive increases in potassium. 

The answer is e. (Hardman, p 708.) Spironolactone is a competitive antagonist of aldosterone that blocks the reabsorption of Na and water from the collecting duct in exchange for K and hydrogen ion retention. Therefore, in the presence of hyperkalemia, spironolactone is contraindicated The administration of each of the other diuretic agents listed results in increased excretion of K. 

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