From the Guidelines
For primary hyperaldosteronism management, the next steps involve confirming the diagnosis through a combination of clinical evaluation, laboratory tests, and imaging studies, as recommended by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1.
Diagnosis Confirmation
If aldosterone-producing adenoma is suspected, consider adrenal venous sampling to confirm lateralization of aldosterone production, as this is a crucial step in determining the appropriate treatment approach 1. The diagnosis of primary aldosteronism generally requires a confirmatory test, such as an intravenous saline suppression test or oral salt-loading test, in addition to the aldosterone:renin activity ratio, which is currently the most accurate and reliable means of screening for primary aldosteronism 1.
Medical Management
Medically, start with spironolactone 25-50 mg daily, titrating up to 100-200 mg daily as needed to control blood pressure and potassium levels, as spironolactone is the most widely available mineralocorticoid receptor antagonist (MRA) 1. Alternatively, eplerenone 25-50 mg daily can be used, titrating up to 100 mg daily, which has the advantage of causing less gynaecomastia and erectile dysfunction in men compared to spironolactone 1. Monitor potassium levels and renal function closely, adjusting medication doses as necessary to avoid potential complications such as hyperkalemia or renal impairment.
Surgical Management
For patients with confirmed unilateral aldosterone-producing adenoma, consider referral to an endocrinologist or surgeon for potential adrenalectomy, which can improve blood pressure control and potentially cure hypertension in about 50% of patients 1. Preoperative medical management with spironolactone or eplerenone should continue until surgery, and postoperative management involves monitoring for hypokalemia and adjusting medication as needed.
Bilateral Adrenal Hyperplasia
In cases of bilateral adrenal hyperplasia, medical management with mineralocorticoid receptor antagonists is the primary treatment approach, and regular follow-up with a healthcare provider is essential to monitor blood pressure, potassium levels, and adjust treatment as necessary 1.
From the FDA Drug Label
2.5 Treatment of Primary Hyperaldosteronism Administer spironolactone in doses of 100 mg to 400 mg daily in preparation for surgery. For patients who are considered unsuitable for surgery, spironolactone can be used as long-term maintenance therapy at the lowest effective dosage determined for the individual patient. 1.4 Primary Hyperaldosteronism Spironolactone tablets are indicated in the following settings: Short-term preoperative treatment of patients with primary hyperaldosteronism. Long-term maintenance therapy for patients with discrete aldosterone-producing adrenal adenomas who are not candidates for surgery Long-term maintenance therapy for patients with bilateral micro or macronodular adrenal hyperplasia (idiopathic hyperaldosteronism).
The next steps for managing Primary Hyperaldosteronism include:
- Short-term preoperative treatment: Administering spironolactone in doses of 100 mg to 400 mg daily in preparation for surgery 2.
- Long-term maintenance therapy: Using spironolactone at the lowest effective dosage determined for the individual patient, for patients who are considered unsuitable for surgery, including those with:
From the Research
Next Steps for Managing Primary Hyperaldosteronism
The next steps for managing Primary Hyperaldosteronism involve a multidisciplinary approach, including:
- Medical management with mineralocorticoid receptor antagonists 3, 4, 5
- Unilateral adrenalectomy for patients with aldosterone-producing adenoma 3, 4, 5, 6
- Pharmacological approaches using mineralocorticoid antagonists for patients with bilateral adrenal hyperplasia 5
Diagnostic Evaluation
The diagnostic evaluation of Primary Hyperaldosteronism should be step-wise, starting with:
- Screening of at-risk populations 7
- Confirmatory testing for positively screened patients 4, 5, 7
- Subtype classification to direct surgical or medical management 4, 5, 7
- Adrenal vein sampling (AVS) to determine subtype classification, reserving deferment of AVS for a selective subset of patients 7
Treatment Outcomes
The treatment outcomes for Primary Hyperaldosteronism depend on various factors, including:
- Preoperative blood pressure level and hypertension duration 5
- Short-term treatment outcome following surgery 5
- Long-term treatment outcome, which is still lacking evidence 5
- Directed treatments comprising of unilateral adrenalectomy or mineralocorticoid antagonists, which can potentially reduce the toxicities of aldosterone 5