title: Eplerenone is not superior to older and less expensive aldosterone antagonists.
abstract: BACKGROUND
  Eplerenone is publicized to be extremely effective in reducing mortality from heart failure, with a reasonable side-effect profile. However, it is much more expensive compared with older aldosterone antagonists. We reviewed available evidence to assess whether increased expense was justified with outcomes data.
  
  
  RESULTS
  The authors searched the PubMed, CENTRAL, CINAHL, and EMBASE databases for randomized controlled trials from 1966 through July 2011. Interventions included aldosterone antagonists (Aldactone [Pfizer, NY, NY], canrenone, eplerenone) in systolic heart failure. The comparator included standard medical therapy or placebo, or both. Outcomes assessed were mortality in the intervention versus the comparator groups, and rates of adverse events at the end of at least 8 weeks of follow-up. Event rates were compared using a forest plot of relative risk (RR) (95% confidence interval [CI]) using a random-effects model (Mantel-Haenszel) between the aldosterone antagonists and controls. We included 13 studies for aldosterone antagonists other than eplerenone, and 3 studies for eplerenone. There was significant reduction of mortality with all aldosterone antagonists, but eplerenone (15% mortality relative reduction; RR 0.85; 95% CI, 0.77-0.93; P=.0007) was outperformed by other aldosterone antagonists, namely, spironolactone and canrenone (26% mortality relative reduction; RR 0.74; 95% CI, 0.66-0.83; P <.0001). Reduction in cardiovascular mortality with eplerenone was 17% (RR 0.83; 95% CI, 0.75-0.92; P=.0005), while that with other aldosterone antagonists was 25% (RR 0.75; 95% CI, 0.67-0.84, P <.0001), without contributing significantly to an improved side-effect profile.
  
  
  CONCLUSIONS
  Eplerenone does not appear to be more effective in reducing clinical events compared with older, less expensive aldosterone antagonists.
authors: Department of Internal Medicine, Maimonides Medical Center, Brooklyn, NY 11220, USA. sauravchatterjeemd@gmail.com
authors: Saurav
authors: S
authors: Chatterjee
authors: Chaim
authors: C
authors: Moeller
authors: Nidhi
authors: N
authors: Shah
authors: Oluwaseyi
authors: O
authors: Bolorunduro
authors: Edgar
authors: E
authors: Lichstein
authors: Norbert
authors: N
authors: Moskovits
authors: Debabrata
authors: D
authors: Mukherjee
mesh_terms: D002192:Canrenone / Q000191:economics / Q000627:therapeutic use; D002423:Cause of Death; D003362:Cost-Benefit Analysis; D016527:Drug Costs / Q000706:statistics & numerical data*; D000077545:Eplerenone; D006333:Heart Failure / Q000188:drug therapy* / Q000191:economics* / Q000401:mortality; D006801:Humans; D000451:Mineralocorticoid Receptor Antagonists / Q000191:economics* / Q000627:therapeutic use; D013148:Spironolactone / Q000031:analogs & derivatives* / Q000191:economics / Q000627:therapeutic use; D015996:Survival Rate; D016896:Treatment Outcome
chemical_list: D000451:Mineralocorticoid Receptor Antagonists; D013148:Spironolactone; D000077545:Eplerenone; D002192:Canrenone