What is the treatment for primary hyperaldosterism?

Treatment of Primary Hyperaldosteronism

The treatment of primary hyperaldosteronism depends on whether it is unilateral or bilateral disease, with unilateral disease treated by laparoscopic adrenalectomy and bilateral disease managed with mineralocorticoid receptor antagonists (MRAs). 1

Diagnostic Approach

Before treatment can be initiated, proper diagnosis and classification is essential:

1. Screening: Plasma aldosterone-to-renin ratio is the most accurate screening test 2

   • Cutoff value: 30 (when aldosterone in ng/dL and renin activity in ng/mL/h)
   • Plasma aldosterone should be at least 10 ng/dL for positive interpretation
   • Patients should have:
     • Unrestricted salt intake
     • Normal serum potassium
     • MRAs withdrawn for at least 4 weeks before testing

2. Confirmatory Testing: Intravenous saline suppression test or oral salt-loading test 2

3. Subtype Differentiation: Adrenal venous sampling to determine if unilateral or bilateral 2

   • Critical for determining appropriate treatment strategy

Treatment Algorithm

1. Unilateral Primary Hyperaldosteronism (≈50% of cases)

• First-line treatment: Laparoscopic adrenalectomy 2, 1

  • Improves blood pressure in virtually 100% of patients
  • Complete cure of hypertension in about 50% of patients
  • Preoperative preparation: Spironolactone 100-400 mg daily 3

• Outcomes after surgery:

  • Normalization of renin-angiotensin-aldosterone system
  • Correction of hypokalemia
  • Regression of cardiovascular, renal, and metabolic complications 4

2. Bilateral Primary Hyperaldosteronism (≈50% of cases)

• First-line treatment: Mineralocorticoid receptor antagonists 2, 1

  a) Spironolactone:

  • Initial dose: 25-100 mg daily 3
  • Can be titrated up to 300-400 mg daily if necessary 1
  • Monitor for side effects: gynecomastia, breast tenderness, menstrual irregularities, sexual dysfunction 1

  b) Eplerenone (alternative with fewer sexual side effects):

  • Initial dose: 25 mg twice daily
  • Can be titrated up to 200 mg daily 1

3. Special Cases

• Familial hyperaldosteronism type 1 (glucocorticoid-remediable):

  • Low-dose dexamethasone 1

• Patients unsuitable for surgery with unilateral disease:

  • Long-term MRA therapy at lowest effective dosage 3

Monitoring

• Check serum electrolytes and creatinine within 1-2 weeks of starting treatment 1
• Ongoing monitoring of:
  • Serum potassium and renal function
  • Blood pressure control
  • Medication side effects

Important Considerations and Pitfalls

1. Risk of hyperkalemia with MRAs: Particularly in patients with renal impairment or when combined with other potassium-sparing medications 1

2. Surgical complications: While laparoscopic adrenalectomy is generally safe, potential surgical risks should be considered

3. Residual hypertension: Even after successful treatment, some patients may require additional antihypertensive medications due to vascular remodeling from delayed diagnosis 1, 5

4. Medication interference: Many medications can interfere with diagnostic testing, requiring careful medication management before testing 6

5. Renal function deterioration: Patients with long-standing disease may experience increased serum creatinine and hyperkalemia when starting spironolactone due to hypertensive kidney damage 7

Primary hyperaldosteronism is associated with significant cardiovascular, renal, and metabolic complications beyond just hypertension. Early diagnosis and appropriate targeted treatment significantly reduce these complications and improve long-term outcomes 4, 8.