From the Guidelines
Spironolactone and Eplerenone are the primary antihypertensive medications used for hyperaldosteronism, with Spironolactone typically started at 25-50mg daily and titrated up to 100-400mg daily as needed, and Eplerenone used at 50-100mg daily as an alternative potassium-sparing diuretic 1. These medications work by blocking aldosterone receptors, directly addressing the underlying pathophysiology of hyperaldosteronism. For patients with severe or resistant hypertension, additional medications may be needed, including calcium channel blockers, ACE inhibitors, or ARBs. Some key points to consider when using these medications include:
- Potassium levels must be monitored regularly to prevent hyperkalemia, especially when using potassium-sparing diuretics like Spironolactone and Eplerenone 1.
- Spironolactone is associated with a greater risk of gynecomastia and impotence compared to Eplerenone, and should be avoided in patients with significant renal dysfunction or those taking K+ supplements or other K+-sparing diuretics 1.
- Eplerenone often requires twice-daily dosing for adequate blood pressure lowering, and is preferred in patients with primary aldosteronism and resistant hypertension 1. In cases of primary hyperaldosteronism due to an adrenal adenoma, surgical removal (adrenalectomy) may be curative, while bilateral adrenal hyperplasia typically requires lifelong medical therapy. Blood pressure goals should target <130/80 mmHg, with medication adjustments made every 2-4 weeks until control is achieved. Some other antihypertensive medications that can be used in hyperaldosteronism include:
- Calcium channel blockers like Amlodipine, which can be used at 2.5-10mg daily 1.
- ACE inhibitors like Lisinopril, which can be used at 10-40mg daily 1.
- ARBs like Losartan, which can be used at 50-100mg daily 1. It's essential to note that the choice of antihypertensive medication should be individualized based on the patient's specific needs and medical history, and that regular monitoring of blood pressure and potassium levels is crucial to ensure effective and safe treatment.
From the FDA Drug Label
2.5 Treatment of Primary Hyperaldosteronism Administer spironolactone tablets in doses of 100 mg to 400 mg daily in preparation for surgery. For patients who are considered unsuitable for surgery, spironolactone tablets 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).
Spironolactone can be used for hyperaldosteronism. The recommended dosage is 100 mg to 400 mg daily. It is indicated for:
- 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) 2 2
From the Research
Anti-Hypertensives for Hyperaldosteronism
- The following anti-hypertensives can be used to treat hyperaldosteronism:
- Spironolactone: a competitive aldosterone receptor antagonist (ARA) that has traditionally been the treatment of first choice in idiopathic hyperaldosteronism (IHA) and for preoperative management of aldosterone producing adenoma (APA) 3
- Eplerenone: a relatively new selective ARA compound with reduced affinity for androgen and progesterone receptors, which is currently undergoing clinical trials 3
- Amiloride: may be used to control hypokaliemia in case of intolerance to spironolactone 4
- Specific calcic inhibitors and thiazide diuretics: may be used as second or third line therapy 4
- New aldosterone blockers: have been developed with different strategies that include use of nonsteroidal MRAs and inhibition of aldosterone synthesis, and are currently having extensive preclinical evaluation 5
- Aldosterone synthase inhibitors: are an attractive alternative, but are prone to interference with cortisol synthesis due to the inhibition of 11-β-hydroxylation 6
Treatment of Primary Aldosteronism
- Medical treatment of primary aldosteronism (PA) seems to be as efficient as surgical treatment of lateralized PA for the control of hypertension and the prevention of cardiovascular and renal morbidities 4
- Spironolactone represents the first line medical treatment of PA, but may present side effects, especially in male patients 4
- Eplerenone may be used in case of intolerance to spironolactone and insufficient control of hypertension by amiloride 4
Treatment of Resistant Hypertension
- Aldosterone antagonists, such as spironolactone, may provide antihypertensive benefit in patients with resistant hypertension and evidence of aldosterone excess 7
- Spironolactone is clearly established as the most effective fourth agent for treatment of uncontrolled resistant hypertension 7
- Emerging observations suggest a further role of spironolactone for counteracting the effects of diet high in sodium, particularly in obese, hypertensive patients 7