What is the initial treatment guideline for primary hyperaldosteronism?

Treatment Guidelines for Primary Hyperaldosteronism

For primary hyperaldosteronism, the initial treatment depends on whether the condition is unilateral or bilateral, with mineralocorticoid receptor antagonists being the first-line medical therapy for bilateral adrenal hyperplasia, which comprises approximately two-thirds of all cases.

Diagnostic Approach First

Before initiating treatment, proper diagnosis and classification is essential:

1. Screening: Use plasma aldosterone:renin activity ratio (ARR) in patients with:

   • Resistant hypertension
   • Hypokalemia (spontaneous or diuretic-induced)
   • Incidentally discovered adrenal mass
   • Family history of early-onset hypertension
   • Stroke at young age (<40 years) 1

2. Confirmatory Testing: If ARR is positive (typically >30 with aldosterone >10 ng/dL), perform:

   • Intravenous saline suppression test or oral salt-loading test 1

3. Subtype Determination: If confirmed, refer for adrenal venous sampling to determine if unilateral or bilateral 1

Treatment Algorithm

For Unilateral Disease (Aldosterone-producing adenoma or unilateral hyperplasia):

• First-line treatment: Laparoscopic adrenalectomy 1
  • Improves BP in virtually 100% of patients
  • Completely cures hypertension in ~50% of cases
  • Reverses target organ damage including LVH

For Bilateral Disease (Idiopathic hyperaldosteronism):

• First-line treatment: Mineralocorticoid receptor antagonists 1, 2
  • Spironolactone: Start at 12.5-25 mg/day, titrate up to 100 mg/day 3
  • Eplerenone: Alternative option at 50-100 mg/day (fewer endocrine side effects) 3, 4

For Patients Unsuitable for Surgery:

• Even with unilateral disease, if surgery is contraindicated, use mineralocorticoid receptor antagonists 2
• Spironolactone dosage: 100-400 mg daily for long-term maintenance 2

Monitoring and Dose Adjustment

• Monitor serum electrolytes and creatinine closely after initiating treatment 3
• Assess BP response and potassium levels regularly
• If BP not normalized with mineralocorticoid receptor antagonists alone, add:
  • Other potassium-sparing diuretics (amiloride or triamterene)
  • Calcium channel blockers 3

Important Considerations

Side Effects to Monitor

• Spironolactone: Gynecomastia, decreased libido, impotence in men; menstrual irregularities in women 4
• Eplerenone: Lower incidence of endocrine side effects due to greater selectivity for mineralocorticoid receptors 4

Treatment Goals

• Reversal of adverse cardiovascular effects of hyperaldosteronism
• Normalization of serum potassium in patients with hypokalemia
• BP control 5

Special Situations

• Pregnancy: Medical treatment preferred 6
• Advanced age: Consider medical therapy as first-line 6
• Hereditary forms: Medical treatment often indicated as first-line therapy 6

Common Pitfalls to Avoid

1. Failure to screen appropriate patients for primary hyperaldosteronism, especially those with resistant hypertension (up to 20% prevalence) 1
2. Inadequate preparation before ARR testing - patients should have unrestricted salt intake, normal potassium levels, and mineralocorticoid antagonists withdrawn for at least 4 weeks 1
3. Insufficient dosing of mineralocorticoid receptor antagonists in bilateral disease
4. Not addressing volume status - sustained volume depletion is a key therapeutic goal 7

Remember that primary aldosteronism causes more target organ damage than primary hypertension at equivalent BP levels, making specific treatment essential for reducing cardiovascular and renal morbidity 1, 6.