What is the treatment for primary aldosteronism (Hyperaldosteronism)?

From the Guidelines

The treatment of primary aldosteronism should be based on whether it is unilateral or bilateral, with laparoscopic adrenalectomy being the preferred treatment for unilateral disease and medical therapy with mineralocorticoid receptor antagonists, such as spironolactone, being recommended for bilateral disease or patients who cannot undergo surgery. The management of primary aldosteronism depends on its subtype, particularly on adrenal lesions being unilateral or bilateral, because the unilateral forms are amenable to surgical treatment while the latter require lifelong medical treatment 1.

Key Considerations

• For unilateral primary aldosteronism, surgical removal of the offending adrenal gland is typically considered, unless the patient is older or has co-morbidities of concern 1.
• Medical treatment is currently based on MRAs, with spironolactone being the most widely available, and its effective dose can be titrated up to 300–400 mg once daily, if necessary 1.
• Eplerenone is also used and has the advantage of causing less gynaecomastia and erectile dysfunction in men, although it is less potent than spironolactone and requires twice-daily administration 1.
• Newer agents, such as the non-steroidal MRAs finerenone and exarenone, and the aldosterone synthase inhibitor baxdrostat, are also being tested for treating primary aldosteronism 1.

Treatment Approach

• The treatment approach should include regular monitoring of blood pressure, serum potassium, and renal function.
• Potassium supplements may be needed initially until levels normalize.
• A low-sodium diet (less than 2.4 g daily) enhances the effectiveness of both surgical and medical treatments.
• For patients with persistent hypertension after adrenalectomy or those on medical therapy, additional antihypertensive medications like calcium channel blockers or ACE inhibitors may be necessary.
• Treatment success is measured by normalization of blood pressure, correction of hypokalemia, and improvement in cardiovascular and renal outcomes.

The most recent and highest quality study, the 2024 ESC guidelines for the management of elevated blood pressure and hypertension, provides the basis for these recommendations 1.

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).

The treatment for primary aldosteronism involves administering spironolactone in doses of 100 mg to 400 mg daily for preparation for surgery or as long-term maintenance therapy at the lowest effective dosage for patients who are not candidates for surgery 2 2. Key points include:

• Short-term preoperative treatment for 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)

From the Research

Treatment Options for Primary Aldosteronism

• Unilateral aldosterone-producing adenoma (APA) and unilateral adrenal hyperplasia are typically treated with endoscopic adrenalectomy, offering a potential cure 3, 4, 5.
• Bilateral adrenal hyperplasia, which accounts for approximately two-thirds of primary hyperaldosteronism cases, is primarily treated with mineralocorticoid receptor antagonists (MRAs) such as spironolactone or eplerenone 3, 6, 5.
• The initial dose of spironolactone is typically 12.5-25mg/day, with titration up to 100mg/day as needed, while eplerenone is started at 50-100mg/day 3, 6.

Medical Management

• If blood pressure is not normalized with MRAs, additional treatment with potassium-sparing diuretics (e.g., amiloride or triamterene) or calcium channel antagonists may be necessary 3.
• The start of medication should be closely monitored by serum electrolyte and creatinine controls to minimize potential side effects 3.
• Eplerenone is a selective aldosterone receptor antagonist that lacks the side effects associated with spironolactone, such as gynecomastia and erectile dysfunction, making it a potentially superior option for some patients 6, 7.

Goals of Treatment

• The primary objectives of treatment for primary aldosteronism are to reverse the adverse cardiovascular effects of hyperaldosteronism, normalize serum potassium levels, and achieve blood pressure control 4, 5.
• Treatment should also aim to reduce associated comorbidities, improve quality of life, and decrease mortality risk 5.