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Potassium Binders Enabling MRA — EECC MCQ

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HardHeart FailurePotassium Binders Enabling MRAEECC

A 75-year-old man with HFrEF and CKD stage 4 (eGFR 22 mL/min) is on ramipril 5 mg, bisoprolol 5 mg, and eplerenone 25 mg. His K⁺ is 5.8 mmol/L on routine bloods. Should eplerenone be stopped?

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Correct answer: C — Use a potassium binder to preserve monitored MRA therapy

Hyperkalaemia (K⁺ >5.5 mmol/L) is a common reason for MRA discontinuation in HF patients with CKD, but premature stopping denies patients a Class I mortality-reducing therapy. The 2023 ESC HF Guidelines recommend using potassium binders (patiromer or sodium zirconium cyclosilicate) as enablers to maintain MRA therapy when hyperkalaemia limits their use (Class IIb). These newer binders have better tolerability than sodium polystyrene sulphonate (Kayexalate). A stepwise approach: reduce MRA dose → add potassium binder → only stop MRA if K⁺ remains >6.0 mmol/L despite these measures. Dietary potassium restriction and correction of metabolic acidosis should also be addressed.

Reference: ESC (2023): Focused Update on Heart Failure: https://www.nice.org.uk/guidance/ng109/chapter/recommendations