From the Guidelines
Hyperaldosteronism is a condition that requires prompt management to prevent cardiovascular complications and kidney damage, with treatment typically involving mineralocorticoid receptor antagonists (MRAs) like spironolactone or eplerenone, and potentially surgery for unilateral cases. The effects of hyperaldosteronism can be significant, leading to high blood pressure, low potassium levels, and increased risk of cardiovascular disease 1. According to the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1, primary aldosteronism is the most common form of secondary hypertension, and its management depends on the subtype, particularly on adrenal lesions being unilateral or bilateral.
Key Considerations
- Primary aldosteronism can be unilateral or bilateral, with unilateral forms being amenable to surgical treatment and bilateral forms requiring lifelong medical treatment 1.
- Medical treatment for primary aldosteronism is currently based on MRAs, with spironolactone being the most widely available 1.
- The effective dose of spironolactone can be titrated up to 300-400 mg once daily, if necessary, while eplerenone is also used, despite being less potent and requiring twice-daily administration 1.
Treatment Options
- 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.
- For bilateral primary aldosteronism, medical treatment with MRAs is the primary option 1.
- Newer agents, such as finerenone and exarenone, and the aldosterone synthase inhibitor baxdrostat, are also being tested for treating primary aldosteronism 1.
Lifestyle Modifications
- Sodium restriction (less than 2.3g daily), weight management, regular exercise, and limiting alcohol are important supportive measures 1.
- Potassium supplementation may be necessary initially but often resolves with proper treatment 1.
Ongoing Monitoring
- Hyperaldosteronism requires ongoing monitoring of blood pressure, electrolytes, and kidney function, as untreated disease can lead to cardiovascular complications and kidney damage due to prolonged exposure to excess aldosterone 1.
From the FDA Drug Label
- 2 Pharmacodynamics Aldosterone antagonist activity: Increased levels of the mineralocorticoid, aldosterone, are present in primary and secondary hyperaldosteronism. Edematous states in which secondary aldosteronism is usually involved include congestive heart failure, hepatic cirrhosis, and nephrotic syndrome By competing with aldosterone for receptor sites, spironolactone provides effective therapy for the edema and ascites in those conditions.
The effects of hyperaldosteronism include:
- Edema
- Ascites
- Congestive heart failure
- Hepatic cirrhosis
- Nephrotic syndrome These conditions are associated with increased levels of the mineralocorticoid aldosterone. Spironolactone, an aldosterone antagonist, can provide effective therapy for these conditions by competing with aldosterone for receptor sites 2.
From the Research
Effects of Hyperaldosteronism
The effects of hyperaldosteronism can be seen in various aspects of the body, including:
- Hypertension: Hyperaldosteronism is characterized by high blood pressure, which can lead to cardiovascular morbidity 3, 4, 5, 6
- Hypokalemia: Excessive aldosterone secretion can cause potassium loss, leading to hypokalemia 3, 7, 5, 6
- Cardiac effects: Aldosterone can promote myocardial fibrosis, leading to cardiac damage 3
- Renal effects: Hyperaldosteronism can cause renal damage, including hypertensive kidney damage and renal arteriolosclerosis 6
Treatment and Management
Treatment and management of hyperaldosteronism include:
- Aldosterone antagonists: Spironolactone is a commonly used treatment, but it can have side effects such as gynecomastia and menstrual irregularities 3, 7, 5, 6
- Alternative therapies: Triamterene-thiazide combination and eplerenone are alternative treatments that can be used in some patients 7, 4
- Surgery: Adrenalectomy can be an effective treatment for patients with primary hyperaldosteronism 6
Diagnosis and Screening
Diagnosis and screening for hyperaldosteronism include:
- Aldosterone/renin ratio: An elevated aldosterone/renin ratio can be used to screen for primary hyperaldosteronism 3, 5, 6
- Plasma renin activity: A low plasma renin activity can be used to predict response to spironolactone treatment 5
- Imaging studies: Computed tomography scans can be used to detect adrenal adenomas 5