NAPLEX Question of the Week: Heart Failure

A very common disease state is the topic of this week's question of the week.

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GW is a 62 year old male who has recently experienced a myocardial infarction that resulted in an ejection fraction of 30%. His other PMH includes diabetes (latest A1c of 8.6%), hypertension, hyperlipidemia, GERD, and hypothyroidism. He currently takes metoprolol succinate 100mg XL daily, lisinopril 40mg daily, levothyroxine 100mcg daily, rosuvastatin 20mg daily, omeprazole 20mg daily, and metformin 1g BID. His cardiologist wants to initiate eplerenone therapy. Which of the following would be considered contraindications to eplerenone therapy? Select all that apply.

A. Sodium < 130 meq/L

B. Potassium > 5.0 meq/L

C. Creatinine clearance < or = 30ml/min

D. Previous gynecomastia from spironolactone

E. Concomitant therapy with itraconazole

Answer with rationale:

The correct answers are C and E. Aldosterone antagonists (also called potassium sparing diuretics) have an important role in the management of heart failure. Eplerenone (Inspra) has been shown to decrease mortality in patients post-MI with resulting heart failure. There are 3 primary contraindications to therapy which include answers C and E as these agents via their mechanism of action increase potassium concentrations. Answer E is also correct as eplerenone is contraindicated with strong 3A4 inhibitors such as itraconazole. Moderate inhibitors, such as fluconazole, can be used with eplerenone but the dose should be capped at 25mg daily. Answer B is incorrect as potassium concentrations > 5.5 meq/L are a contraindication to eplerenone therapy.  Answer D is incorrect as gynecomastia, while common with spironolactone therapy, is often a reason to switch to eplerenone if gynecomastia occurs on spironolactone therapy.  Answer A is incorrect as hyponatremia is not a contraindication to eplerenone therapy. 

Christopher M. Bland

Clinical Associate Professor, University of Georgia College of Pharmacy

Dr. Christopher M. Bland is a Clinical Associate Professor at the University of Georgia College of Pharmacy at the Southeast GA campus in Savannah, GA. Dr. Bland has over 20 years of academic and clinical experience in a number of clinical areas. He is a Fellow of both the Infectious Diseases Society of America as well as the American College of Clinical Pharmacy. He is co-founder of the Southeastern Research Group Endeavor, SERGE-45, with over 80 practitioners across 14 states involved. Dr. Bland serves as Associate Editor for the NAPLEX Review Guide 4th edition as well as Editor-In-Chief for the Question of the Week. He has provided live, interactive reviews for more than 10 Colleges/Schools of Pharmacy over the course of his career.