What is the treatment for hyperaldosteronism?

Treatment of Hyperaldosteronism

The treatment of hyperaldosteronism depends primarily on whether it is unilateral or bilateral, with unilateral disease typically managed surgically through adrenalectomy and bilateral disease treated with mineralocorticoid receptor antagonists. 1

Diagnosis and Classification

Before initiating treatment, proper classification is essential:

1. Diagnostic confirmation:

   • Plasma aldosterone-to-renin ratio is the most accurate screening test 1
   • Confirmatory testing (saline suppression or oral salt loading) 1
   • Adrenal vein sampling to distinguish unilateral from bilateral disease 1

2. Classification:

   • Unilateral: Usually aldosterone-producing adenoma (APA)
   • Bilateral: Idiopathic hyperaldosteronism (bilateral adrenal hyperplasia)
   • Familial forms: Require genetic testing 1

Treatment Algorithm

Unilateral Primary Aldosteronism

• First-line treatment: Surgical removal (laparoscopic adrenalectomy) of the affected adrenal gland 1
• Exceptions: Surgery may not be recommended for:
  • Older patients
  • Patients with significant comorbidities 1
  • In these cases, medical management as per bilateral disease is indicated

Bilateral Primary Aldosteronism (approximately 2/3 of cases)

• First-line treatment: Mineralocorticoid receptor antagonists (MRAs) 1

  • Spironolactone:

    • Starting dose: 25-50 mg once daily 2
    • Titrate to 50-100 mg daily 1
    • Can be increased up to 300-400 mg daily if necessary 1
    • FDA-approved dosing for primary hyperaldosteronism: 100-400 mg daily 2

  • Eplerenone (alternative if spironolactone not tolerated):

    • Less potent than spironolactone
    • Requires twice-daily administration
    • Advantage: Fewer sexual side effects (less gynecomastia and erectile dysfunction) 1, 3
    • Typical dosing: 25 mg twice daily, can be titrated up to 200 mg daily 3

Familial Hyperaldosteronism

• Glucocorticoid-remediable aldosteronism (Type 1):
  • Treated with low-dose dexamethasone 1
  • Safe to use during pregnancy

Inadequate Response to First-line Treatment

If blood pressure remains uncontrolled on MRAs:

1. Add potassium-sparing diuretics (amiloride or triamterene) 4
2. Add calcium channel blockers 4
3. Consider adding thiazide diuretics if needed 3

Monitoring and Follow-up

• Initial monitoring:

  • Serum electrolytes and creatinine within 1-2 weeks of starting treatment 4
  • Blood pressure at regular intervals

• Ongoing monitoring:

  • Serum potassium and renal function
  • Blood pressure control
  • Side effects of medications

Special Considerations

Side Effects of Spironolactone

• Gynecomastia and breast tenderness in men
• Menstrual irregularities in women
• Sexual dysfunction (decreased libido, impotence)
• Hyperkalemia (especially in patients with renal impairment) 5

Emerging Treatments

• Newer non-steroidal MRAs (finerenone, exarenone)
• Aldosterone synthase inhibitor (baxdrostat)
• These agents are being tested for primary aldosteronism 1

Clinical Pearls and Pitfalls

• Pearl: Early diagnosis and treatment lead to higher cure rates and better outcomes 1
• Pitfall: Vascular remodeling from delayed diagnosis may result in residual hypertension even after treatment 1
• Pearl: Eplerenone can be substituted for spironolactone if side effects occur, with similar efficacy in blood pressure control 3
• Pitfall: Careful monitoring of potassium is essential when starting MRAs, especially in patients with renal impairment
• Pearl: Bilateral adrenal hyperplasia accounts for approximately 60% of primary aldosteronism cases and requires lifelong medical therapy 1

Primary aldosteronism is the most common form of secondary hypertension, and appropriate treatment significantly reduces cardiovascular and renal complications associated with excess aldosterone production.