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Spironolactone Gynaecomastia Alternative — ESENeph MCQ

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HardElectrolyte DisordersSpironolactone Gynaecomastia AlternativeESENeph

A man with HFrEF and CKD G3a develops painful bilateral gynaecomastia on spironolactone. Potassium is 4.4 mmol/L and eGFR 48 mL/min/1.73m². Mineralocorticoid-receptor blockade remains indicated. What is the most rational substitution?

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Correct answer: E — Use eplerenone with renal-function and potassium-guided dosing and monitoring

Explanation lettering: B = shown as A · A = shown as B · E = shown as C · C = shown as D · D = shown as E

D is correct. Spironolactone can produce dose- and duration-related gynaecomastia through off-target sex-steroid receptor effects. Eplerenone is more selective and is the appropriate evidence-based MRA substitution in HFrEF when renal function and potassium permit. It still causes hyperkalaemia, so eGFR-dependent dosing and early potassium surveillance are essential. Finerenone has separate licensed populations and should not be imported automatically into this scenario; amiloride and triamterene do not reproduce the HFrEF outcome evidence. Increasing spironolactone exposure is likely to worsen rather than remove the adverse effect.

Reference: UK eplerenone Summary of Product Characteristics: https://www.medicines.org.uk/emc/product/120/smpc