From the Guidelines
In medically treated primary hyperaldosteronism, the target renin level should be in the upper normal range or slightly elevated, aiming for plasma renin activity (PRA) levels between the upper quarter of the normal range and twice the upper limit of normal, typically corresponding to PRA values of approximately 1-4 ng/mL/hr, as suggested by the most recent guidelines 1. To achieve this target, mineralocorticoid receptor antagonists like spironolactone or eplerenone are used, with doses adjusted based on blood pressure control, serum potassium levels, and renin measurements. Some key points to consider when managing primary hyperaldosteronism include:
- The use of spironolactone, starting at 50–100 mg once daily, which can be titrated up to 300–400 mg once daily if necessary, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.
- The consideration of alternative agents, such as eplerenone, which has the advantage of causing less gynaecomastia and erectile dysfunction in men, despite being less potent than spironolactone and requiring twice-daily administration.
- Regular monitoring of renin, potassium, and renal function is essential, typically every 4-12 weeks during dose adjustment and then every 6-12 months once stable, to ensure adequate mineralocorticoid receptor blockade and prevent overtreatment. The diagnosis and management of primary hyperaldosteronism require a comprehensive approach, including confirmatory tests, such as the intravenous saline suppression test or oral salt-loading test, and adrenal venous sampling to determine the origin of aldosterone production, as outlined in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. However, when it comes to medically treated primary hyperaldosteronism, the focus is on achieving the target renin level through the use of mineralocorticoid receptor antagonists, with the goal of improving blood pressure control, reducing morbidity, and enhancing quality of life.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Medically Treated Primary Hyperaldosteronism
The renin target in medically treated primary hyperaldosteronism is an important aspect of managing the condition.
- The goal of medical therapy is to control blood pressure, normalize serum potassium levels, and increase renin levels 2.
- A rise in renin is considered a key biomarker of optimized medical therapy, indicating a reversal of the pathophysiology of primary aldosteronism and restoration of normal physiology 2.
- Medical treatment options include mineralocorticoid receptor antagonists, such as spironolactone and eplerenone, which can help to increase renin levels and improve blood pressure control 3, 2.
- The aldosterone/renin ratio is also an important metric in diagnosing and managing primary hyperaldosteronism, with a ratio >20 indicating primary aldosteronism 4.
- However, in some cases, renin levels may not be suppressed, even in the presence of high aldosterone levels, due to secondary hypertensive kidney damage 5.
- In these cases, medical treatment with spironolactone or other mineralocorticoid receptor antagonists may still be effective in controlling blood pressure and increasing renin levels, but requires careful monitoring of serum creatinine and potassium levels 5.