Switching should be considered as part of shared decision making, as the value placed on avoiding gynaecomastia varies from patient to patient. Overall, the clinically important reduction in all-cause mortality and hospitalisation supported a recommendation to offer MRAs to all people with HFREF who remain symptomatic despite treatment with beta-blockers and ACE inhibitors. The committee also recommended baseline measurement and regular monitoring of patients renal function and potassium levels, as well as drug interactions, and that clinicians seek specialist advice in the case of deterioration (rather than automatically discontinuing the MRA). The committee discussed the intervals at which patients taking MRAs should Chronic Heart Failure Treating Heart Failure NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 be monitored and agreed that this should take place before starting an MRA, 1-2 weeks after commencing the medicine and after each dose increment. Once a person had reached their target or highest tolerated dose they should be monitored monthly for 3 months to ensure no adverse effects. After this, the committee agreed that 6 monthly monitoring was sufficient or when a person became acutely unwell. The importance of measuring blood pressure after each dose increment was also stressed by the committee as postural hypotension was a common cause of hospital admission in the elderly. For further explanation of the monitoring recommendations please see section 4.3.8 of the methodology section of the guideline and appendix D. Trade-off between net clinical effects and costs Two relevant economic analyses were identified that compared the additional use of mineralcorticoid receptor antagonists to optimal medical management. One UK economic evaluation assessed the addition of eplerenone to optimal medical management based on the EMPHASIS-HF trial included in the clinical review. 