KEY POINTS AND PRACTICAL RECOMMENDATIONS: • Mineralocorticoid receptor (MR) antagonists (aldosterone blockers) provide effective antihypertensive treatment, especially in low-renin and salt-sensitive forms of hypertension, including resistant hypertension. • Newer, more selective MR antagonists (eg, eplerenone) have fewer of the progestational and antiandrogenic effects than spironolactone, enhancing tolerability and potentially improving adherence to therapy. • MR antagonists provide an additional benefit in the treatment of heart failure when combined with angiotensin-converting enzyme inhibitors, digoxin, and loop diuretics. • Other potassium-sparing diuretics (amiloride or triamterene) are generally prescribed for essential hypertension as a fixed-dose combination with hydrochlorothiazide. • The dose range for spironolactone with resistant hypertension is between 25 mg/d and 50 mg/d, and eplerenone is an appropriate alternative if spironolactone is not tolerated because of sexual side effects. • In general, the combined use of spironolactone and adequate doses of a thiazide diuretic or a thiazide-like agent such as chlorthalidone for the treatment of resistant hypertension maximizes efficacy and reduces the risk of spironolactone-induced hyperkalemia.
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