From the Guidelines
For a patient with resistant hypertension and primary hyperaldosteronism who refuses surgery, the best next step is to initiate medical therapy with a mineralocorticoid receptor antagonist, specifically eplerenone. This approach is supported by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1, which recommend medical treatment based on mineralocorticoid receptor antagonists (MRAs) for bilateral primary aldosteronism, as surgery is not an option. Given the patient's condition and refusal of surgery, eplerenone is a suitable choice due to its effectiveness in treating primary aldosteronism and its advantage of causing less gynaecomastia and erectile dysfunction in men compared to spironolactone 1. The patient's current medication regimen and medical history should be considered when initiating eplerenone therapy, and potassium levels should be monitored regularly to avoid hyperkalemia. Additionally, lifestyle modifications such as sodium restriction, weight loss, regular exercise, and limiting alcohol consumption should be recommended to the patient to help achieve blood pressure control. The use of eplerenone in resistant hypertension is also supported by the 2024 ESC guidelines, which suggest the addition of low-dose spironolactone or eplerenone to existing treatment for patients with resistant hypertension 1. Overall, initiating medical therapy with eplerenone is the most appropriate next step for this patient, given the current evidence and guidelines.
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: ... Long-term maintenance therapy for patients with bilateral micro or macronodular adrenal hyperplasia (idiopathic hyperaldosteronism).
The most appropriate next step in management for this patient with resistant hypertension and primary hyperaldosteronism who refuses surgery is B Eplerenone therapy or alternatively, spironolactone therapy, as both are mineralocorticoid receptor antagonists that can be used for the treatment of primary hyperaldosteronism in patients who are not candidates for surgery. However, since the question does not mention spironolactone as an option and eplerenone is a similar medication, Eplerenone therapy is the chosen answer. 2 2
From the Research
Resistant Hypertension Management
The patient has resistant hypertension and primary hyperaldosteronism, with a screening plasma aldosterone concentration/plasma renin activity ratio of >20 and diffuse bilateral adrenal hyperplasia on adrenal CT scan. The patient refuses surgery.
Treatment Options
- The patient is already on multiple antihypertensive medications, including amlodipine, enalapril, metoprolol, and chlorthalidone.
- Considering the patient's primary hyperaldosteronism, a mineralocorticoid receptor antagonist (MRA) such as eplerenone or spironolactone may be beneficial 3, 4, 5, 6.
- Eplerenone has been shown to be effective in patients with resistant hypertension and primary hyperaldosteronism, with a significant reduction in blood pressure and minimal side effects 4, 7.
- Spironolactone is also an effective MRA, but it may have more side effects, such as anti-androgenic effects, compared to eplerenone 3, 4.
Next Step
- Given the patient's refusal of surgery and the presence of primary hyperaldosteronism, initiating eplerenone therapy may be the most appropriate next step in management.
- Eplerenone has been shown to be effective in reducing blood pressure in patients with resistant hypertension and primary hyperaldosteronism, and it may be better tolerated than spironolactone 4, 7.
- The patient's potassium levels and renal function should be closely monitored while on eplerenone therapy 3, 4, 6.
Choice
B Eplerenone therapy is the most appropriate next step in management.