Spironolactone initiation and dosing in adults with heart failure with preserved ejection fraction

SGLT2: sodium-glucose co-transporter 2; BNP: B-type natriuretic peptide; NTpro-BNP: N-terminal pro-BNP; HF: heart failure; eGFR: estimated glomerular filtration rate.
* If not euvolemic, adjust diuretics and reevaluate for spironolactone use. Refer to UpToDate content on the use of diuretics in patients with heart failure.
¶ SGLT2 inhibitors are contraindicated in all patients with type 1 diabetes and should be avoided in patients with type 2 diabetes with a history of diabetic ketoacidosis, frequent urinary tract infections, eGFR <20 mL/min/1.73 m², and risk factors for foot amputation. Refer to UpToDate content for details on the precautions, dosing, and monitoring of SGLT2 inhibitor therapy.
Δ If the potassium level is ≤4.2 mEq/L and renal function is normal, spironolactone can be started at 25 mg daily.
◊ In countries where spironolactone is available in 15 mg tablets, the initial dose is 15 mg, and the dose is titrated in 15 mg increments to a maximum dose of 45 mg.
§ If gynecomastia develops, change spironolactone to eplerenone.