What are the next steps for managing Primary Hyperaldosteronism (Conn's Syndrome)?

From the Guidelines

The next steps for managing Primary Hyperaldosteronism (Conn's Syndrome) should focus on appropriate screening, diagnosis, and targeted treatment, with the goal of reducing morbidity, mortality, and improving quality of life, as recommended by the most recent guidelines 1.

Key Considerations

• Patients with resistant hypertension, hypokalemia, adrenal incidentaloma, or family history of early-onset hypertension should undergo screening with plasma aldosterone concentration (PAC) to plasma renin activity (PRA) ratio.
• If screening is positive, confirmatory testing with salt loading, captopril challenge, or fludrocortisone suppression test should follow.
• Adrenal imaging with CT or MRI helps identify adenomas, while adrenal vein sampling is crucial for lateralization in surgical candidates.

Treatment Options

• For unilateral aldosterone-producing adenomas, laparoscopic adrenalectomy is the preferred treatment, often normalizing potassium levels and improving blood pressure control.
• For bilateral adrenal hyperplasia or patients unsuitable for surgery, medical therapy with mineralocorticoid receptor antagonists is recommended, starting with spironolactone 25-50 mg daily, titrating up to 100-400 mg daily as needed, or eplerenone 25-50 mg twice daily for fewer anti-androgenic side effects.

Monitoring and Follow-up

• Blood pressure targets should be <130/80 mmHg, with regular monitoring of electrolytes, particularly potassium and creatinine, especially during dose adjustments.
• This approach targets the pathophysiology of excess aldosterone, which promotes sodium retention, potassium excretion, and subsequent hypertension and end-organ damage, as supported by recent guidelines 1.

From the FDA Drug Label

2.5 Treatment of Primary Hyperaldosteronism Administer spironolactone in doses of 100 mg to 400 mg daily in preparation for surgery. For patients who are considered unsuitable for surgery, spironolactone 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 next steps for managing Primary Hyperaldosteronism (Conn's Syndrome) include:

• Short-term preoperative treatment: Administering spironolactone in doses of 100 mg to 400 mg daily to prepare patients for surgery 2.
• Long-term maintenance therapy: Using spironolactone at the lowest effective dosage for patients who are not candidates for surgery, including those with:
  • Discrete aldosterone-producing adrenal adenomas 2.
  • Bilateral micro or macronodular adrenal hyperplasia (idiopathic hyperaldosteronism) 2.

From the Research

Treatment Options for Primary Hyperaldosteronism (Conn's Syndrome)

• Unilateral adrenalectomy is the treatment of choice for unilateral cases, offering the possibility of cure 3, 4
• Bilateral forms of Primary Hyperaldosteronism are treated mainly with mineralocorticoid receptor antagonists (MRA) 5, 3, 4, 6
• The goals of treatment for Primary Hyperaldosteronism include reversal of the adverse cardiovascular effects of hyperaldosteronism, normalization of serum potassium in patients with hypokalemia, and normalization of blood pressure 3

Medical Management

• Mineralocorticoid receptor antagonists, such as spironolactone (starting dose 12.5-25mg/day with titration up to 100mg/day) or eplerenone (50-100mg/day), are used as first-line treatment for bilateral Primary Hyperaldosteronism 5, 6
• Potassium-sparing diuretics (amiloride or triamterene) or calcium channel antagonists may be added if blood pressure is not normalized by MRA treatment alone 5
• Esaxerenone, a safe mineralocorticoid receptor antagonist, has been shown to have strong antihypertensive and anti-albuminuric effects 7
• Aldosterone synthase inhibitors (ASIs) have been developed as antihypertensive agents with a new mechanism of action, blocking aldosterone secretion from the adrenal gland 7

Surgical and Alternative Treatments

• Unilateral adrenalectomy is the preferred treatment for lateralized Primary Hyperaldosteronism, offering the possibility of cure and mitigating the risk of cardiovascular and renal complications 3, 4
• Robot-assisted laparoscopic adrenalectomy, percutaneous computed tomography radiofrequency ablation, transvenous radiofrequency catheter ablation, and super-selective adrenal arterial embolization are alternative treatments that have been developed 7

Lifestyle Modifications

• Dietary salt restriction and appropriate calorie intake to avoid fat accumulation are recommended to suppress overactivation of the mineralocorticoid receptor (MR) and control blood pressure 7