From the Guidelines
Angiotensin II receptor blockers (ARBs) can be used in hyperaldosteronism, but they are generally not first-line therapy. For primary hyperaldosteronism, mineralocorticoid receptor antagonists like spironolactone (25-100 mg daily) or eplerenone (25-50 mg daily) are the preferred medical treatments as they directly block aldosterone's effects 1. ARBs such as losartan (25-100 mg daily), valsartan (80-320 mg daily), or irbesartan (150-300 mg daily) may be added as adjunctive therapy, particularly when blood pressure control remains inadequate or when patients cannot tolerate mineralocorticoid receptor antagonists.
Key Considerations
- The diagnosis of primary aldosteronism generally requires a confirmatory test (intravenous saline suppression test or oral salt-loading test) 1.
- Patients with primary aldosteronism have a higher risk of cardiovascular and kidney damage, and screening of patients with hypertension at increased risk of primary aldosteronism is beneficial 1.
- The aldosterone:renin activity ratio is currently the most accurate and reliable means of screening for primary aldosteronism 1.
Treatment Approach
- Mineralocorticoid receptor antagonists are the preferred medical treatments for primary hyperaldosteronism 1.
- ARBs may be used as adjunctive therapy, particularly when blood pressure control remains inadequate or when patients cannot tolerate mineralocorticoid receptor antagonists.
- In secondary hyperaldosteronism, where the renin-angiotensin-aldosterone system is activated, ARBs may be more effective as they target the underlying pathophysiology 1.
Important Notes
- Hypokalemia is absent in the majority of cases and has a low negative predictive value for the diagnosis of primary aldosteronism 1.
- The deleterious effects of aldosterone overproduction are often reversible with unilateral laparoscopic adrenalectomy or treatment with mineralocorticoid receptor antagonists 1.
From the Research
Use of ARBs in Hyperaldosteronism
- The use of Angiotensin Receptor Blockers (ARBs) in hyperaldosteronism is not directly addressed in the provided studies as a primary treatment option.
- However, according to 2, in patients with normal aldosterone levels, ARBs or ACE inhibitors are used as a first-line therapy, and MR antagonists may be used as an add-on agent.
- Additionally, 3 mentions that the antihypertensive benefit of spironolactone was additive to chronic renin-angiotensin blockade with angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) in patients with resistant hypertension.
- It is also noted in 4 that there is a phenomenon of "aldosterone escape" occurring with angiotensin-converting enzyme inhibitor and angiotensin-receptor blockade therapy, which may suggest a potential limitation of using ARBs alone in hyperaldosteronism.
Alternative Treatment Options
- Mineralocorticoid receptor (MR) antagonists, such as spironolactone and eplerenone, are commonly used in the treatment of hyperaldosteronism, as they provide effective antihypertensive treatment and reduce target-organ damage 5, 3, 4.
- Adrenalectomy may be considered as a first-choice procedure in patients with unilateral primary aldosteronism 2.
- Optimal doses of mineralocorticoid receptor antagonists can control symptoms and normalize plasma renin activity in patients with hyperaldosteronism 6.