How is primary aldosteronism (primary aldosterone) managed?

From the Guidelines

Primary aldosteronism is managed through targeted treatments based on its subtype, with surgical removal of the offending adrenal gland typically considered for unilateral primary aldosteronism, and medical treatment with mineralocorticoid receptor antagonists (MRAs) such as spironolactone or eplerenone for bilateral primary aldosteronism. 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.

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. The effective dose of spironolactone, usually 50–100 mg once daily, can be titrated up to 300–400 mg once daily, if necessary 1. Eplerenone is also used and, despite being less potent than spironolactone and requiring twice-daily administration, it has the advantage of causing less gynaecomastia and erectile dysfunction in men.

Some key points to consider in the management of primary aldosteronism include:

• The use of adrenal vein sampling or functional imaging with radiolabelled tracers to distinguish between unilateral and bilateral primary aldosteronism 1
• The importance of monitoring blood pressure, serum potassium, and renal function regularly, with laboratory checks recommended 1-2 weeks after starting therapy or changing doses
• The need for patients to follow a low-sodium diet (less than 2.3 g daily) to help control blood pressure
• The use of potassium supplementation initially until aldosterone blockade takes effect
• The consideration of newer agents, such as the non-steroidal MRAs finerenone and exarenone, and the aldosterone synthase inhibitor baxdrostat, which lower BP in resistant hypertension, for the treatment of primary aldosteronism 1.

It is also important to note that the diagnosis of primary aldosteronism generally requires a confirmatory test, such as the intravenous saline suppression test or oral salt-loading test, and that patients should have unrestricted salt intake, serum potassium in the normal range, and mineralocorticoid receptor antagonists withdrawn for at least 4 weeks before testing 1.

Overall, the management of primary aldosteronism requires a comprehensive approach that takes into account the subtype of the disease, the patient's overall health, and the potential benefits and risks of different treatment options. The goal of treatment is to normalize blood pressure, correct hypokalemia, and prevent cardiovascular and renal complications, while also minimizing the risk of adverse effects.

From the FDA Drug Label

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).

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.

Management of Primary Aldosteronism:

• Short-term preoperative treatment: Spironolactone 100-400 mg daily
• Long-term maintenance therapy: Spironolactone at the lowest effective dosage, for patients not suitable for surgery or with bilateral micro or macronodular adrenal hyperplasia 2, 2 Key considerations:
• Dosage titration and monitoring are crucial to determine the effective dosage for each patient
• Patients should be closely monitored for hyperkalemia, especially when taking other medications that increase potassium levels 2

From the Research

Management of Primary Aldosteronism

The management of primary aldosteronism (primary aldosterone) involves accurate subtype distinction and assessment of unilateral versus bilateral disease 3. The treatment strategies can be summarized as follows:

• Bilateral Idiopathic Hyperaldosteronism: This subtype is best managed pharmacologically, with the use of aldosterone receptor antagonists such as spironolactone or eplerenone 3, 4. Combined treatment with sodium-channel blockers and calcium-channel blockers has also shown satisfactory results 3.
• Glucocorticoid-Remediable Aldosteronism: This subtype responds well to treatment with low-dose glucocorticoids 3.
• Aldosterone-Producing Adenoma and Unilateral Adrenal Hyperplasia: These subtypes are appropriately treated with laparoscopic adrenalectomy, which improves blood pressure in 98% of patients, although only about 33% require no further antihypertensive medication 3.
• Refractory Cases: In rare cases, bilateral adrenalectomy may be necessary, as reported in a case study of a patient with refractory primary aldosteronism due to bilateral hyperplasia 5.

Pharmacological Treatment

Pharmacological treatment of primary aldosteronism typically involves the use of:

• Mineralocorticoid Receptor Antagonists (MRAs): Such as spironolactone and eplerenone, which are effective in controlling blood pressure and hypokalemia 6, 4.
• Potassium-Sparing Diuretics: Such as amiloride or triamterene, which may be used in addition to MRAs if blood pressure is not normalized 4.
• Calcium Channel Antagonists: Which may also be used in combination with MRAs to control blood pressure 4.

Goals of Treatment

The goals of treatment for primary aldosteronism extend beyond the normalization of blood pressure and hypokalemia, and include:

• Normalization of Circulating Aldosterone: Or mineralocorticoid blockade to prevent aldosterone-induced tissue damage 7.
• Prevention of Cardiovascular Events and Target Organ Damage: Which are more common in patients with primary aldosteronism than in those with essential hypertension 7.