From the Guidelines
The initial treatment for hyperaldosteronism typically begins with mineralocorticoid receptor antagonists (MRAs) such as spironolactone, with a usual dose of 50–100 mg once daily, which can be titrated up to 300–400 mg once daily if necessary, as recommended by the most recent guidelines 1.
Key Considerations
- 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, whereas surgery is not an option for bilateral primary aldosteronism 1.
- Medical treatment is currently based on MRAs, with spironolactone being the most widely available, and eplerenone also used, despite being less potent and requiring twice-daily administration, but with the advantage of causing less gynaecomastia and erectile dysfunction in men 1.
Treatment Approach
- The treatment approach should include:
- MRAs such as spironolactone or eplerenone to block aldosterone's effects and control hypertension and normalize potassium levels.
- Potassium supplementation if hypokalemia is present.
- Blood pressure and electrolyte monitoring, with dosage adjustments made accordingly.
- Lifestyle modifications, including sodium restriction (less than 2.3g daily), as important adjunctive measures.
Recent Guidelines
- The 2024 ESC guidelines for the management of elevated blood pressure and hypertension recommend the use of MRAs as the initial treatment for hyperaldosteronism, with spironolactone being the most widely available option 1.
- The guidelines also emphasize the importance of distinguishing between unilateral and bilateral primary aldosteronism, as this determines the treatment approach, with surgical removal being an option for unilateral cases, and lifelong medical therapy being required for bilateral cases 1.
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.
The initial treatment for primary hyperaldosteronism is administering spironolactone in doses of 100 mg to 400 mg daily in preparation for surgery, or as long-term maintenance therapy for patients who are not candidates for surgery, at the lowest effective dosage determined for the individual patient 2.
- The dosage can vary depending on the individual patient's needs and response to treatment.
- Spironolactone is used to treat primary hyperaldosteronism in patients who are either preparing for surgery or are not suitable for surgery 2.
From the Research
Initial Treatment for Hyperaldosteronism
The initial treatment for hyperaldosteronism depends on the underlying cause of the condition.
- For patients with aldosterone-producing adenoma and unilateral adrenal hyperplasia, the initial treatment is endoscopic adrenalectomy 3.
- For patients with bilateral adrenal hyperplasia, the initial treatment is mineralocorticoid receptor antagonists, such as spironolactone or eplerenone 3, 4, 5.
Medication Treatment
The medication treatment for hyperaldosteronism typically starts with a low dose of spironolactone (12.5-25mg/day) or eplerenone (50-100mg/day), with titration up to 100mg/day for spironolactone or 200mg for eplerenone if necessary 3, 5.
- If blood pressure is not normalized by this first-line treatment, additional treatment with potassium-sparing diuretics (such as amiloride or triamterene) or calcium channel antagonists may be necessary 3.
Monitoring and Follow-up
The start of medication should be closely monitored by serum electrolyte and creatinine controls 3.
- Regular follow-up appointments are necessary to assess the effectiveness of treatment and make any necessary adjustments to the treatment plan.
Comparison of Spironolactone and Eplerenone
Both spironolactone and eplerenone are effective in reducing blood pressure in patients with idiopathic hyperaldosteronism, with similar efficacy and safety profiles 5.
- However, eplerenone may have a more rapid onset of action and a lower risk of side effects such as gynecomastia 5.