What is the diagnostic and treatment approach for hyperaldosteronism?

From the Guidelines

Hyperaldosteronism diagnosis and treatment should begin with screening high-risk patients using the aldosterone-to-renin ratio (ARR), followed by confirmatory testing and imaging to guide treatment decisions, prioritizing laparoscopic adrenalectomy for unilateral aldosterone-producing adenomas and medical therapy with mineralocorticoid receptor antagonists for bilateral adrenal hyperplasia. The diagnostic approach for hyperaldosteronism involves assessing plasma aldosterone and renin activity, with a plasma aldosterone-to-renin ratio greater than 30 indicating primary hyperaldosteronism 1. Confirmatory testing with the saline suppression test or salt loading test may be necessary to rule out false-positives and false-negatives.

Diagnostic Approach

• Screening high-risk patients, such as those with resistant hypertension, hypokalemia, adrenal incidentaloma, or family history, using the aldosterone-to-renin ratio (ARR) 1
• Confirmatory testing, including oral sodium loading, saline infusion, fludrocortisone suppression, or captopril challenge tests
• Imaging with adrenal CT or MRI to identify adenomas
• Adrenal vein sampling to distinguish between unilateral and bilateral disease

Treatment Approach

• Unilateral aldosterone-producing adenomas: laparoscopic adrenalectomy is recommended, which can cure or significantly improve hypertension 1
• Bilateral adrenal hyperplasia: medical therapy is preferred, primarily with mineralocorticoid receptor antagonists like spironolactone (starting at 12.5-25 mg daily, titrating up to 100-400 mg daily as needed) or eplerenone (25-50 mg twice daily) 1
• Monitoring blood pressure, potassium levels, and renal function regularly, especially when initiating or adjusting medication doses, is crucial to prevent cardiovascular and renal complications associated with long-standing hyperaldosteronism.

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 diagnostic and treatment approach for primary hyperaldosteronism involves:

• Short-term preoperative treatment: Administering spironolactone tablets in doses of 100 mg to 400 mg daily in preparation for surgery 2.
• Long-term maintenance therapy: Using spironolactone tablets at the lowest effective dosage determined for the individual patient, for patients who are not candidates for surgery or have bilateral micro or macronodular adrenal hyperplasia (idiopathic hyperaldosteronism) 2. Key points:
• Spironolactone tablets are indicated for the treatment of primary hyperaldosteronism.
• The dosage and administration of spironolactone tablets vary depending on the individual patient's needs and response to treatment.

From the Research

Diagnostic Approach

• The diagnostic approach for hyperaldosteronism typically involves initial screening and subsequent confirmatory testing to establish a biochemical diagnosis 3.
• The ratio of plasma aldosterone concentration to plasma renin activity (PAC/PRA) is considered a useful screening test for primary aldosteronism, with a ratio above 50 suggesting hyperaldosteronism 4.
• The PAC/PRA ratio can be used to aid in the diagnosis of hyperaldosteronism, even in patients with normal aldosterone levels and normokalemia 4, 5.
• Other diagnostic tests, such as abdominal computed tomography scans and adrenal vein sampling, may be necessary to determine the subtype of hyperaldosteronism and to identify potential surgical candidates 3.

Treatment Approach

• Medical therapy using mineralocorticoid receptor antagonists, such as spironolactone, can control symptoms and normalize plasma renin activity in patients with hyperaldosteronism 4, 3.
• Targeted pharmacotherapy can lead to normalization of blood values and improvement in blood pressure control 4.
• Surgical treatment may be necessary for some patients with hyperaldosteronism, particularly those with unilateral adrenal disease 3.
• The long-term outcome of patients treated with either surgical or optimal medical therapy appears similar 3.

Clinical Considerations

• Hyperaldosteronism is a relatively common disorder that can increase the risk of cardiovascular events 3, 6.
• Patients with hyperaldosteronism may have normal serum potassium levels, and hypokalemia is not a necessary criterion for diagnosis 4, 5.
• The diagnosis of hyperaldosteronism should be considered in patients with resistant hypertension, even if they have normal serum potassium levels 4.
• The aldosterone:PRA ratio provides fair diagnostic accuracy in screening for primary aldosteronism, but concomitant antihypertensive drug therapy or acute variation in dietary sodium balance does not adversely affect test accuracy 7.