Eplerenone

A selective mineralocorticoid receptor antagonist. Aldosterone tells the kidneys to hold on to sodium and water, which raises blood pressure and fluid volume. Blocking that receptor lowers both. Spironolactone does the same job but hits androgen and progesterone receptors along the way, which is how you get gynecomastia, breast tenderness, and a crushed libido on it. Eplerenone skips those off-target receptors. For men running compounds that already stress the hormonal axis, that selectivity is the entire reason to reach for it.

It is weaker milligram-for-milligram than spironolactone, so the doses run higher. The trade is a cleaner side profile, and for most men in this audience, that trade is worth it.

Heart-failure mortality data from two large trials, blood-pressure evidence from dose-ranging work, and a network meta-analysis ranking eplerenone above spironolactone:

Start at 25 mg once daily. Check serum potassium and creatinine at baseline, again at four to six weeks, and any time you change the dose or add another drug that affects potassium. If blood pressure is still not controlled and potassium stays below 5.0, move to 50 mg. In heart failure, 50 mg is the ceiling. For blood pressure alone, dose-response trials tested up to 100 mg daily with increasing effect, though potassium monitoring scales with the dose. If potassium climbs above 5.5 at any dose, cut back or stop.

Eplerenone pairs naturally with telmisartan or another ARB for blood pressure, or with nebivolol if heart rate is also elevated. The ARB combination raises potassium risk, which is manageable with bloodwork, not guesswork.

The side profile is remarkably clean outside of one number: