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Management of Primary Aldosteronism (Hyperaldosteronism)

For patients with primary aldosteronism, treatment should be guided by whether the condition is unilateral or bilateral, with laparoscopic adrenalectomy for unilateral disease and mineralocorticoid receptor antagonists (spironolactone or eplerenone) for bilateral disease. 1

Diagnostic Approach

1. Screening:

   • Use plasma aldosterone-to-renin ratio (ARR) as the primary screening test
   • Cutoff value: ARR > 30 with plasma aldosterone ≥ 10 ng/dL
   • Patient preparation: unrestricted salt intake, normal serum potassium, and mineralocorticoid receptor antagonists withdrawn for at least 4 weeks 2

2. Confirmatory Testing:

   • Intravenous saline suppression test or oral salt-loading test 2
   • Required to definitively diagnose primary aldosteronism

3. Subtype Determination:

   • Adrenal venous sampling to determine if aldosterone production is unilateral or bilateral 2
   • Critical step that determines treatment approach

Treatment Algorithm

1. Unilateral Primary Aldosteronism

• First-line treatment: Laparoscopic adrenalectomy 2, 1
• Outcomes:
  • Improves blood pressure in virtually 100% of patients
  • Complete cure of hypertension in approximately 50% of patients
  • Resolves hypokalemia and improves cardiac and kidney function 2

2. Bilateral Primary Aldosteronism

• First-line treatment: Mineralocorticoid receptor antagonists 2, 1
  • Spironolactone:
    • Starting dose: 12.5-25 mg daily
    • Can be titrated to 50-100 mg daily, up to 300-400 mg if necessary 2, 1
  • Eplerenone (alternative with fewer sexual side effects):
    • Starting dose: 25 mg daily
    • Can be titrated to 50 mg daily, up to 200 mg if necessary 2, 1

3. Special Considerations

• Glucocorticoid-remediable aldosteronism: Treat with low-dose dexamethasone 1
• Nonsurgical candidates with unilateral disease: Use mineralocorticoid receptor antagonists 2

Monitoring and Follow-up

1. Initial Monitoring:

   • Check serum potassium and renal function within 1-2 weeks of starting treatment 1
   • Monitor for hyperkalemia, especially when combined with ACE inhibitors 2

2. Long-term Monitoring:

   • Regular assessment of blood pressure control
   • Periodic measurement of serum potassium and renal function
   • Watch for side effects: gynecomastia, sexual dysfunction, menstrual irregularities 1

Important Considerations

• Risk of hyperkalemia: Increases when serum creatinine is >1.6 mg/dL; determine that GFR or creatinine clearance is >30 mL/min/1.73 m² in elderly patients 2
• Potassium monitoring: Check potassium levels and renal function 3 days and 1 week after initiating therapy, then monthly for the first 3 months 2
• Medication interactions: Risk of hyperkalemia increases with concomitant use of higher doses of ACE inhibitors 2
• Potassium supplements: Should be discontinued or reduced when initiating aldosterone antagonists 2

Clinical Relevance and Underdiagnosis

Primary aldosteronism is significantly underdiagnosed despite being the most common form of secondary hypertension, affecting up to 5-10% of hypertensive patients 3, 4. Recent research shows that the prevalence is much higher than previously thought, with estimates of 11.3% in normotension, 15.7% in stage 1 hypertension, 21.6% in stage 2 hypertension, and 22.0% in resistant hypertension 4.

Early diagnosis and treatment are crucial as aldosterone excess has adverse cardiovascular consequences beyond hypertension, and specific treatment can significantly reduce this excess morbidity and mortality 3, 5.