USA: Simultaneous use of patiromer and high-dose mineralocorticoid receptor antagonist (MRA) lowers the risk of recurrent hyperkalemia in patients with heart failure and reduced ejection fraction (HFrEF), a new study has found. Also, it enables specific target doses of renin-angiotensin-aldosterone system inhibitor (RAASi). The study appears in the European Heart Journal.
The study was conducted by Javed Butler, Department of Medicine, University of Mississippi, Jackson, Mississippi, USA, and colleagues with the objective to investigate the impact of patiromer on serum potassium levels and its ability to enable specified target doses of RAAS inhibitors use in HFrEF patients.

For this purpose, the researchers screened a total of 1642 patients with HFrEF and current or a history of RAASi-related hyperkalemia, out of which 1195 were enrolled in the run-in phase with patiromer and optimization of RAASi therapy (≥50% recommended dose of angiotensin-converting-enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor, and 50 mg of mineralocorticoid receptor antagonist [MRA] spironolactone or eplerenone).
All patients, physicians, and outcome assessors were blinded to treatment assignment. The between-group difference in adjusted mean change in serum potassium was the primary endpoint. Five hierarchical secondary endpoints were assessed.
The findings of the study were as follows:
Specified target doses of RAASi therapy were achieved in 878 (84.6%) patients; 439 were randomized to patiromer and 439 to placebo.
At the end of treatment, the median (interquartile range) duration of follow-up was 27 (13, 43) weeks, the adjusted mean change in potassium was +0.03 mmol/L in the patiromer group and +0.13 mmol/L in the placebo group (difference in adjusted mean change between patiromer and placebo: -0.10 mmol/L).
Risk of hyperkalemia >5.5 mmol/L (hazard ratio [HR] 0.63), reduction of MRA dose (HR 0.62), and total adjusted hyperkalemia events/100 person-years (77.7 vs. 118.2; HR 0.66) were lower with patiromer.
Hyperkalemia-related morbidity-adjusted events (win ratio 1.53, P<0.001) and total RAASi use score (win ratio 1.25) favored the patiromer arm.
Adverse events were similar between groups.
The researchers conclude, "patiromer use simultaneously reduces the risk of recurrent hyperkalemia and enables specified target doses of RAAS inhibitors."
Reference:
Javed Butler, MD, MPH, MBA, Stefan D Anker, MD PhD, Lars H Lund, MD PhD, Andrew J S Coats, DM, DSc, MBA, Gerasimos Filippatos, MD PhD, Tariq Jamal Siddiqi, MD, Tim Friede, PhD, Vincent Fabien, PhD, Mikhail Kosiborod, MD, Marco Metra, MD, Ileana L Piña, MD, Fausto Pinto, MD PhD, Patrick Rossignol, MD PhD, Peter van der Meer, MD PhD, Cecilia Bahit, MD, Jan Belohlavek, MD PhD, Michael Böhm, MD, Jasper J Brugts, MD PhD, John GF Cleland, MD, Justin Ezekowitz, MBBCh, Antoni Bayes-Genis, MD PhD, Israel Gotsman, MD, Assen Goudev, MD PhD, Irakli Khintibidze, MD PhD, Joann Lindenfeld, MD, Robert J Mentz, MD, Bela Merkely, MD PhD, Eliodoro Castro Montes, MD, Wilfried Mullens, MD PhD, Jose C Nicolau, MD PhD, Aleksandr Parkhomenko, MD PhD, Piotr Ponikowski, MD PhD, Petar M Seferovic, MD PhD, Michele Senni, MD PhD, Evgeny Shlyakhto, MD PhD, Alain Cohen-Solal, MD PhD, Peter Szecsödy, MD, Klaus Jensen, MD, Fabio Dorigotti, MD, Matthew R Weir, MD, Bertram Pitt, MD, Patiromer for the management of hyperkalemia in heart failure with reduced ejection fraction: the DIAMOND trial, European Heart Journal, 2022;, ehac401, https://doi.org/10.1093/eurheartj/ehac401