VB is a 68 year old female who has recently experienced a myocardial infarction that resulted in an ejection fraction of 30%. Her other PMH includes diabetes (latest A1c of 8.6%), hypertension, hyperlipidemia, and hypothyroidism. She currently takes metoprolol succinate 50mg XL daily, lisinopril 20mg daily, levothyroxine 100mcg daily, atorvastatin 40mg daily, and metformin 1g BID. Her 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 > 5.5 meq/L
C. Creatinine clearance < or = 30ml/min
D. Concomitant therapy with fluconazole
E. Concomitant therapy with ketoconazole
Answer with rationale:
The correct answers are B, 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 B and C 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 ketoconazole. Answer D is incorrect as fluconazole is a moderate 3A4 inhibitor and therefore can be given with eplerenone but the maximum dosage is 25mg daily. Answer A is incorrect as hyponatremia is not a contraindication to eplerenone therapy.