Routine co-prescribing of potassium sparing diuretics in combination with thiazide or loop diuretics should be avoided except in patients where hypokalaemia has been demonstrated or in patients not taking an ACE inhibitor who are at risk from hypokalaemia e.g. those with severe CHD and arrhythmias and those taking digoxin. See Pharmacological treatment of symptomatic heart failure due to left ventricular systolic dysfunction

Amiloride

• Tablets 5mg (£15.07 = 28 tablets)
• Oral solution sugar free 5mg in 5ml (£158.85 = 150ml)

Indications

• Potassium conservation when used as an adjunct to thiazide or loop diuretics

Dose

• Used alone, initially 10mg daily or 5mg twice daily, adjusted according to response; maximum 20mg daily
• With other diuretics, congestive heart failure and hypertension, initially 5–10mg daily; cirrhosis with ascites, initially 5mg daily

Aldosterone antagonists

Spironolactone

• Tablets 25mg, 50mg, 100mg (£4.81 = 100mg daily)
• Oral suspension sugar free 5mg in 5ml, 25mg in 5ml, 50mg in 5ml (unlicensed preparations) (£22.68 = 50mg in 5ml x 125ml)

Indications

• Moderate to severe heart failure
• Resistant hypertension (unlicensed indication)

Dose

• Moderate to severe heart failure (adjunct): initially 25mg once daily, increased according to response to maximum 50mg once daily
• Resistant hypertension (adjunct): 25mg once daily (unlicensed indication)

Notes

1. In severe heart failure, spironolactone added to other treatments in a low dose can reduce mortality and morbidity. Careful monitoring for hyperkalaemia and hypovolaemia is required especially for people taking other diuretics and/or ACE inhibitors.
2. Regularly monitor serum potassium levels and renal function. The recommended monitoring for potassium and creatinine is 1 week after initiation or increase in dose, monthly for the first 3 months, then quarterly for a year, and then every 6 months. Discontinue or interrupt treatment for serum potassium >5 mmol/L (5 mEq/L) or for serum creatinine >350umol/L (approximately 4mg/dL)

Eplerenone

• Tablets 25mg, 50mg (£3.86 = 50mg daily)

Indications

• Heart failure

Dose

• Initially 25mg once daily, increased within 4 weeks to 50mg once daily

Notes

1. It is expected that treatment will be commenced within specialist care
2. Eplerenone has been shown to reduce mortality in patients developing heart failure post MI when initiated within 3-14 days. It may be initiated at a dose of 25mg provided serum potassium less than 5mmol/L and should be titrated to 50mg within 4 weeks unless serum potassium exceeds 5mmol/L. If the serum potassium exceeds 5.5mmol/L, the dose should be reduced or withheld (consult product literature).
3. Regularly monitor serum potassium levels and renal function. The recommended monitoring for potassium and creatinine is 1 week after initiation or increase in dose, monthly for the first 3 months, then quarterly for a year, and then every 6 months.
4. Eplerenone should only be initiated when spironolactone is contraindicated or not tolerated, may be useful when patients have symptomatic gynaecomastia literature).

Finerenone

• Tablets 10mg, 20mg

​Notes​

1. NICE TA877: Finerenone (​Kerendia​) ​is recommended​ as an option for treating stage 3 and 4 chronic kidney disease (with albuminuria) associated with type 2 diabetes in adults (March 2023), only if:
1. it is an add-on to optimised standard care; this should include, unless they are unsuitable, the highest tolerated licensed dose of:
1. angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) ​and​
2. sodium-glucose cotransporter-2 (SGLT2) inhibitors ​and​
2. the person has an estimated glomerular filtration rate (eGFR) of 25 ml/min/1.73m²​ or more.