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GDMT Drug Interactions - Hyperkalaemia — EECC MCQ

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EasyHeart FailureGDMT Drug Interactions - HyperkalaemiaEECC

A 60-year-old man with HFrEF (LVEF 25%) and sinus rhythm (HR 68 bpm) is on sacubitril/valsartan 97/103 mg bd, carvedilol 25 mg bd, eplerenone 50 mg, and dapagliflozin 10 mg. His renal function is stable (eGFR 48 mL/min). He asks whether his HF medications interact with each other in a clinically important way. Which interaction is most clinically relevant?

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Correct answer: D — Monitor potassium and renal function with ARNI plus MRA

The combination of sacubitril/valsartan (which has ARB and neprilysin inhibitor components) with eplerenone (MRA) increases the risk of hyperkalaemia through dual RAAS blockade and aldosterone receptor antagonism. While this combination is standard in HFrEF GDMT (and the benefits outweigh the risks), it mandates regular monitoring of serum potassium and renal function (within 1-2 weeks of initiation/dose change, then periodically). The risk is amplified by CKD, diabetes, and NSAIDs. The ESC HF Guidelines recommend checking K⁺ and creatinine within 1-2 weeks of starting or changing RAAS inhibitors or MRAs, and at least every 4 months thereafter. Potassium binders (patiromer, SZC) may enable continuation of both agents if hyperkalaemia develops.

Reference: ESC (2023): Focused Update on Heart Failure: https://bnf.nice.org.uk/