Eplerenone

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Eplerenone
Adult Indications & Dosage
Pediatric Indications & Dosage
Contraindications
Warnings & Precautions
Adverse Reactions
Drug Interactions
Use in Specific Populations
Administration & Monitoring
Overdosage
Pharmacology
Clinical Studies
How Supplied
Images
Patient Counseling Information
Precautions with Alcohol
Brand Names
Look-Alike Names

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Gerald Chi

Disclaimer

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Overview

Eplerenone is a aldosterone antagonist that is FDA approved for the {{{indicationType}}} of hypertension and congestive heart failure after myocardial infarction. Common adverse reactions include hyperkalemia, diarrhea, dizziness, elevated serum creatinine, cough, and fatigue.

Adult Indications and Dosage

FDA-Labeled Indications and Dosage (Adult)

Congestive Heart Failure Post-Myocardial Infarction

Eplerenone tablets are indicated to improve survival of stable patients with left ventricular (LV) systolic dysfunction (ejection fraction ≤40%) and clinical evidence of congestive heart failure (CHF) after an acute myocardial infarction.

  • Dosing Information
  • Treatment should be initiated at 25 mg once daily and titrated to the recommended dose of 50 mg once daily, preferably within 4 weeks as tolerated by the patient.
  • Eplerenone tablets may be administered with or without food.
  • Once treatment with eplerenone tablets have begun, adjust the dose based on the serum potassium level as shown in the table below.
This image is provided by the National Library of Medicine.
Hypertension
  • Dosing Information
  • The recommended starting dose of eplerenone tablets are 50 mg once daily.
  • The full therapeutic effect of eplerenone tablets is apparent within 4 weeks.
  • For patients with an inadequate blood pressure response to 50 mg once daily the dosage of eplerenone tablets should be increased to 50 mg twice daily. Higher dosages of eplerenone tablets are not recommended because they have no greater effect on blood pressure than 100 mg and are associated with an increased risk of hyperkalemia.
Dose Modifications for Specific Populations
  • Serum potassium levels should be measured before initiating eplerenone tablet therapy, and eplerenone tablets should not be prescribed if serum potassium is >5.5 mEq/L.
  • No adjustment of the starting dose is recommended for the elderly or for patients with mild-to-moderate hepatic impairment.

Off-Label Use and Dosage (Adult)

Guideline-Supported Use

Heart Failure, Myocardial infarction with Complication
  • Dosing Information
  • 25 mg daily initially, titrated to a maximum of 50 mg/day[1]

Non–Guideline-Supported Use

Albuminuria in Diabetes Mellitus
  • Dosing Information
  • 50 mg once daily[2]
Low-Renin Essential Hypertension
  • Dosing Information
  • 100 mg once daily[3]
Systolic Heart Failure (Mild)
  • Dosing Information

Pediatric Indications and Dosage

FDA-Labeled Indications and Dosage (Pediatric)

  • Eplerenone tablets has not been studied in hypertensive patients less than 4 years old because the study in older pediatric patients did not demonstrate effectiveness.
  • Eplerenone has not been studied in pediatric patients with heart failure.

Off-Label Use and Dosage (Pediatric)

Guideline-Supported Use

There is limited information regarding Off-Label Guideline-Supported Use of Eplerenone in pediatric patients.

Non–Guideline-Supported Use

There is limited information regarding Off-Label Non–Guideline-Supported Use of Eplerenone in pediatric patients.

Contraindications

For All Patients
For Patients Treated for Hypertension

Warnings

Hyperkalemia
  • Minimize the risk of hyperkalemia with proper patient selection and monitoring, and avoidance of certain concomitant medications. Monitor patients for the development of hyperkalemia until the effect of eplerenone tablets are established. Patients who develop hyperkalemia (>5.5 mEq/L) may continue eplerenone tablets therapy with proper dose adjustment. Dose reduction decreases potassium levels.
  • The rates of hyperkalemia increase with declining renal function. Patients with hypertension who have serum creatinine levels >2.0 mg/dL (males) or >1.8 mg/dL (females) or creatinine clearance ≤50 mL/min should not be treated with eplerenone tablets. Patients with CHF post-MI who have serum creatinine levels >2.0 mg/dL (males) or >1.8 mg/dL (females) or creatinine clearance ≤50 mL/min should be treated with eplerenone tablets with caution.
Impaired Hepatic Function
  • Mild-to-moderate hepatic impairment did not increase the incidence of hyperkalemia. In 16 subjects with mild-to-moderate hepatic impairment who received 400 mg of eplerenone, no elevations of serum potassium above 5.5 mEq/L were observed. The mean increase in serum potassium was 0.12 mEq/L in patients with hepatic impairment and 0.13 mEq/L in normal controls. The use of eplerenone tablets in patients with severe hepatic impairment has not been evaluated.
Impaired Renal Function
  • Patients with decreased renal function are at increased risk of hyperkalemia.

Adverse Reactions

Clinical Trials Experience

Congestive Heart Failure Post-Myocardial Infarction
  • In EPHESUS, safety was evaluated in 3307 patients treated with eplerenone tablets and 3301 placebo-treated patients. The overall incidence of adverse events reported with eplerenone tablets (78.9%) was similar to placebo (79.5%). Adverse events occurred at a similar rate regardless of age, gender, or race. Patients discontinued treatment due to an adverse event at similar rates in either treatment group (4.4% eplerenone tablets vs. 4.3% placebo), with the most common reasons for discontinuation being hyperkalemia, myocardial infarction, and abnormal renal function.
  • Adverse reactions that occurred more frequently in patients treated with eplerenone tablets than placebo were hyperkalemia (3.4% vs. 2.0%) and increased creatinine (2.4% vs. 1.5%). Discontinuations due to hyperkalemia or abnormal renal function were less than 1.0% in both groups. Hypokalemia occurred less frequently in patients treated with eplerenone tablets (0.6% vs. 1.6%).
  • The rates of sex hormone-related adverse events are shown in the table below.
This image is provided by the National Library of Medicine.
Hypertension
  • Eplerenone tablets has been evaluated for safety in 3091 patients treated for hypertension. A total of 690 patients were treated for over 6 months and 106 patients were treated for over 1 year.
  • In placebo-controlled studies, the overall rates of adverse events were 47% with eplerenone tablets and 45% with placebo. Adverse events occurred at a similar rate regardless of age, gender, or race. Therapy was discontinued due to an adverse event in 3% of patients treated with eplerenone tablets and 3% of patients given placebo. The most common reasons for discontinuation of eplerenone tablets were headache, dizziness, angina pectoris/myocardial infarction, and increased GGT. The adverse events that were reported at a rate of at least 1% of patients and at a higher rate in patients treated with eplerenone tablets in daily doses of 25 to 400 mg versus placebo are shown in the table below.
This image is provided by the National Library of Medicine.
  • Gynecomastia and abnormal vaginal bleeding were reported with eplerenone tablets but not with placebo. The rates of these sex hormone-related adverse events are shown in the table below. The rates increased slightly with increasing duration of therapy. In females, abnormal vaginal bleeding was also reported in 0.8% of patients on antihypertensive medications (other than spironolactone) in active control arms of the studies with eplerenone tablets.
This image is provided by the National Library of Medicine.

Clinical Laboratory Test Findings

Congestive Heart Failure Post-Myocardial Infarction
  • Increases of more than 0.5 mg/dL were reported for 6.5% of patients administered eplerenone tablets and for 4.9% of placebo-treated patients.
  • In EPHESUS, the frequencies of patients with changes in potassium (<3.5 mEq/L or >5.5 mEq/L or ≥6.0 mEq/L) receiving eplerenone tablets compared with placebo are displayed in the table below.
This image is provided by the National Library of Medicine.
This image is provided by the National Library of Medicine.
This image is provided by the National Library of Medicine.
Hypertension
  • In placebo-controlled fixed-dose studies, the mean increases in serum potassium were dose-related and are shown in the table below along with the frequencies of values >5.5 mEq/L.
This image is provided by the National Library of Medicine.
  • Patients with both type 2 diabetes and microalbuminuria are at increased risk of developing persistent hyperkalemia. In a study of such patients taking eplerenone tablets 200 mg, the frequencies of maximum serum potassium levels >5.5 mEq/L were 33% with eplerenone tablets given alone and 38% when eplerenone tablets were given with enalapril.
  • Rates of hyperkalemia increased with decreasing renal function. In all studies, serum potassium elevations >5.5 mEq/L were observed in 10.4% of patients treated with eplerenone tablets with baseline calculated creatinine clearance <70 mL/min, 5.6% of patients with baseline creatinine clearance of 70 to 100 mL/min, and 2.6% of patients with baseline creatinine clearance of >100 mL/min.
  • Serum sodium decreased in a dose-related manner. Mean decreases ranged from 0.7 mEq/L at 50 mg daily to 1.7 mEq/L at 400 mg daily. Decreases in sodium (<135 mEq/L) were reported for 2.3% of patients administered eplerenone tablets and 0.6% of placebo-treated patients.
  • Serum triglycerides increased in a dose-related manner. Mean increases ranged from 7.1 mg/dL at 50 mg daily to 26.6 mg/dL at 400 mg daily. Increases in triglycerides (above 252 mg/dL) were reported for 15% of patients administered eplerenone tablets and 12% of placebo-treated patients.
  • Serum cholesterol increased in a dose-related manner. Mean changes ranged from a decrease of 0.4 mg/dL at 50 mg daily to an increase of 11.6 mg/dL at 400 mg daily. Increases in serum cholesterol values greater than 200 mg/dL were reported for 0.3% of patients administered eplerenone tablets and 0% of placebo-treated patients.
  • Liver Function Tests
  • Serum alanine aminotransferase (ALT) and gamma glutamyl transpeptidase (GGT) increased in a dose-related manner. Mean increases ranged from 0.8 U/L at 50 mg daily to 4.8 U/L at 400 mg daily for ALT and 3.1 U/L at 50 mg daily to 11.3 U/L at 400 mg daily for GGT. Increases in ALT levels greater than 120 U/L (3 times upper limit of normal) were reported for 15/2259 patients administered eplerenone tablets and 1/351 placebo-treated patients. Increases in ALT levels greater than 200 U/L (5 times upper limit of normal) were reported for 5/2259 of patients administered eplerenone tablets and 1/351 placebo-treated patients. Increases of ALT greater than 120 U/L and bilirubin greater than 1.2 mg/dL were reported 1/2259 patients administered eplerenone tablets and 0/351 placebo-treated patients. Hepatic failure was not reported in patients receiving eplerenone tablets.
  • Serum creatinine increased in a dose-related manner. Mean increases ranged from 0.01 mg/dL at 50 mg daily to 0.03 mg/dL at 400 mg daily. Increases in blood urea nitrogen to greater than 30 mg/dL and serum creatinine to greater than 2 mg/dL were reported for 0.5% and 0.2%, respectively, of patients administered eplerenone tablets and 0% of placebo-treated patients.
  • Increases in uric acid to greater than 9 mg/dL were reported in 0.3% of patients administered eplerenone tablets and 0% of placebo-treated patients.

Postmarketing Experience

The following adverse reactions have been identified during post approval use of eplerenone tablets. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Skin

Angioneurotic edema and rash

Drug Interactions

  • Because eplerenone metabolism is predominantly mediated via CYP3A4, do not use eplerenone tablets with drugs that are strong inhibitors of CYP3A4.
  • In patients with hypertension taking moderate CYP3A4 inhibitors, reduce the starting dose of eplerenone tablets to 25 mg once daily.
  • Congestive Heart Failure Post-Myocardial Infarction
  • In EPHESUS, 3020 (91%) patients receiving eplerenone tablets 25 to 50 mg also received angiotensin II receptor antagonists. Rates of patients with maximum potassium levels >5.5 mEq/L were similar regardless of the use of angiotensin II receptor antagonists.
  • Hypertension
  • A drug interaction study of eplerenone with lithium has not been conducted. Lithium toxicity has been reported in patients receiving lithium concomitantly with diuretics and ACE inhibitors. Serum lithium levels should be monitored frequently if eplerenone tablets is administered concomitantly with lithium.
  • A drug interaction study of eplerenone with an NSAID has not been conducted. The administration of other potassium-sparing antihypertensives with NSAIDs has been shown to reduce the antihypertensive effect in some patients and result in severe hyperkalemia in patients with impaired renal function. Therefore, when eplerenone tablets and NSAIDs are used concomitantly, patients should be observed to determine whether the desired effect on blood pressure is obtained and monitored for changes in serum potassium levels.

Use in Specific Populations

Pregnancy

Pregnancy Category (FDA):

  • Pregnancy Category B
  • There are no adequate and well-controlled studies in pregnant women. Eplerenone tablets should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
  • Embryo-fetal development studies were conducted with doses up to 1000 mg/kg/day in rats and 300 mg/kg/day in rabbits (exposures up to 32 and 31 times the human AUC for the 100 mg/day therapeutic dose, respectively). No teratogenic effects were seen in rats or rabbits, although decreased body weight in maternal rabbits and increased rabbit fetal resorptions and post-implantation loss were observed at the highest administered dosage. Because animal reproduction studies are not always predictive of human response, eplerenone tablets should be used during pregnancy only if clearly needed.


Pregnancy Category (AUS): There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Eplerenone in women who are pregnant.

Labor and Delivery

There is no FDA guidance on use of Eplerenone during labor and delivery.

Nursing Mothers

  • The concentration of eplerenone in human breast milk after oral administration is unknown. However, preclinical data show that eplerenone and/or metabolites are present in rat breast milk (0.85:1 [milk: plasma] AUC ratio) obtained after a single oral dose. Peak concentrations in plasma and milk were obtained from 0.5 to 1 hour after dosing. Rat pups exposed by this route developed normally. Because many drugs are excreted in human milk and because of the unknown potential for adverse effects on the nursing infant, a decision should be made whether to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother.

Pediatric Use

  • In a 10-week study of 304 hypertensive pediatric patients age 4 to 17 years treated with eplerenone tablets up to 100 mg per day, doses that produced exposure similar to that in adults, eplerenone tablets did not lower blood pressure effectively. In this study and in a 1-year pediatric safety study in 149 patients, the incidence of reported adverse events was similar to that of adults.
  • Eplerenone tablets has not been studied in hypertensive patients less than 4 years old because the study in older pediatric patients did not demonstrate effectiveness.
  • Eplerenone has not been studied in pediatric patients with heart failure.

Geriatic Use

  • Congestive Heart Failure Post-Myocardial Infarction
  • Of the total number of patients in EPHESUS, 3340 (50%) were 65 and over, while 1326 (20%) were 75 and over. Patients greater than 75 years did not appear to benefit from the use of eplerenone tablets.
  • No differences in overall incidence of adverse events were observed between elderly and younger patients. However, due to age-related decreases in creatinine clearance, the incidence of laboratory-documented hyperkalemia was increased in patients 65 and older.
  • Hypertension
  • Of the total number of subjects in clinical hypertension studies of eplerenone tablets, 1123 (23%) were 65 and over, while 212 (4%) were 75 and over. No overall differences in safety or effectiveness were observed between elderly subjects and younger subjects.

Gender

There is no FDA guidance on the use of Eplerenone with respect to specific gender populations.

Race

There is no FDA guidance on the use of Eplerenone with respect to specific racial populations.

Renal Impairment

There is no FDA guidance on the use of Eplerenone in patients with renal impairment.

Hepatic Impairment

There is no FDA guidance on the use of Eplerenone in patients with hepatic impairment.

Females of Reproductive Potential and Males

There is no FDA guidance on the use of Eplerenone in women of reproductive potentials and males.

Immunocompromised Patients

There is no FDA guidance one the use of Eplerenone in patients who are immunocompromised.

Administration and Monitoring

Administration

Oral

Monitoring

  • Serum potassium should be measured before initiating eplerenone tablet therapy, within the first week, and at one month after the start of treatment or dose adjustment. Serum potassium should be assessed periodically thereafter. Patient characteristics and serum potassium levels may indicate that additional monitoring is appropriate. In the EPHESUS study, the majority of hyperkalemia was observed within the first three months after randomization.
  • In all patients taking eplerenone tablets who start taking a moderate CYP3A4 inhibitor, check serum potassium and serum creatinine in 3 to 7 days.

IV Compatibility

There is limited information regarding IV Compatibility of Eplerenone in the drug label.

Overdosage

Acute Overdose

Signs and Symptoms

  • No cases of human overdosage with eplerenone have been reported.
  • Lethality was not observed in mice, rats, or dogs after single oral doses that provided Cmax exposures at least 25 times higher than in humans receiving eplerenone 100 mg/day.

Management

  • Eplerenone has been shown to bind extensively to charcoal.
  • If symptomatic hypotension should occur, supportive treatment should be instituted.
  • If hyperkalemia develops, standard treatment should be initiated.

Chronic Overdose

There is limited information regarding Chronic Overdose of Eplerenone in the drug label.

Pharmacology

There is limited information regarding Eplerenone Pharmacology in the drug label.

Mechanism of Action

  • Eplerenone has been shown to produce sustained increases in plasma renin and serum aldosterone, consistent with inhibition of the negative regulatory feedback of aldosterone on renin secretion. The resulting increased plasma renin activity and aldosterone circulating levels do not overcome the effects of eplerenone.

Structure

  • Eplerenone tablets contain eplerenone, a blocker of aldosterone binding at the mineralocorticoid receptor.
  • Eplerenone is chemically described as Pregn-4-ene-7,21-dicarboxylic acid, 9,11-epoxy-17-hydroxy-3-oxo-, γ-lactone, methyl ester, (7α,11α,17α)-. Its empirical formula is C24H30O6 and it has a molecular weight of 414.50. The structural formula of eplerenone is represented below:
This image is provided by the National Library of Medicine.
  • Eplerenone is an odorless, white to off-white crystalline powder. It is very slightly soluble in water, with its solubility essentially pH-independent. The octanol/water partition coefficient of eplerenone is approximately 7.1 at pH 7.0.
  • Eplerenone tablets for oral administration contains 25 mg or 50 mg of eplerenone and the following inactive ingredients: microcrystalline cellulose, povidone, croscarmellose sodium, hypromellose, hydroxypropyl cellulose, magnesium stearate, titanium dioxide, polyethylene glycol, and iron oxide yellow.

Pharmacodynamics

There is limited information regarding Pharmacodynamics of Eplerenone in the drug label.

Pharmacokinetics

xx

Nonclinical Toxicology

There is limited information regarding Nonclinical Toxicology of Eplerenone in the drug label.

Clinical Studies

There is limited information regarding Clinical Studies of Eplerenone in the drug label.

Condition1

Description

How Supplied

There is limited information regarding Eplerenone How Supplied in the drug label.

Storage

There is limited information regarding Eplerenone Storage in the drug label.

Images

Drug Images

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Package and Label Display Panel

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Patient Counseling Information

There is limited information regarding Patient Counseling Information of Eplerenone in the drug label.

Precautions with Alcohol

Alcohol-Eplerenone interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

Brand Names

Inspra®

Look-Alike Drug Names

  • Inspra® — Spiriva®[6]

Drug Shortage Status

Price

References

The contents of this FDA label are provided by the National Library of Medicine.

  1. ↑ Pitt, Bertram; Remme, Willem; Zannad, Faiez; Neaton, James; Martinez, Felipe; Roniker, Barbara; Bittman, Richard; Hurley, Steve; Kleiman, Jay; Gatlin, Marjorie (2003). "Eplerenone, a Selective Aldosterone Blocker, in Patients with Left Ventricular Dysfunction after Myocardial Infarction". New England Journal of Medicine. 348 (14): 1309–1321. doi:10.1056/NEJMoa030207. ISSN 0028-4793.
  2. ↑ Epstein, M. (2006). "Selective Aldosterone Blockade with Eplerenone Reduces Albuminuria in Patients with Type 2 Diabetes". Clinical Journal of the American Society of Nephrology. 1 (5): 940–951. doi:10.2215/CJN.00240106. ISSN 1555-9041.
  3. ↑ Weinberger, Myron H.; White, William B.; Ruilope, Luis-Miguel; MacDonald, Thomas M.; Davidson, Robert C.; Roniker, Barbara; Patrick, Jeffrey L.; Krause, Scott L. (2005). "Effects of eplerenone versus losartan in patients with low-renin hypertension". American Heart Journal. 150 (3): 426–433. doi:10.1016/j.ahj.2004.12.005. ISSN 0002-8703.
  4. ↑ Zannad, Faiez; McMurray, John J.V.; Krum, Henry; van Veldhuisen, Dirk J.; Swedberg, Karl; Shi, Harry; Vincent, John; Pocock, Stuart J.; Pitt, Bertram (2011). "Eplerenone in Patients with Systolic Heart Failure and Mild Symptoms". New England Journal of Medicine. 364 (1): 11–21. doi:10.1056/NEJMoa1009492. ISSN 0028-4793.
  5. ↑ Swedberg, Karl; Zannad, Faiez; McMurray, John J.V.; Krum, Henry; van Veldhuisen, Dirk J.; Shi, Harry; Vincent, John; Pitt, Bertram (2012). "Eplerenone and Atrial Fibrillation in Mild Systolic Heart Failure". Journal of the American College of Cardiology. 59 (18): 1598–1603. doi:10.1016/j.jacc.2011.11.063. ISSN 0735-1097.
  6. ↑ "http://www.ismp.org". External link in |title= (help)


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