What is the recommended treatment for a patient with hyperaldosteronism (elevated aldosterone), low renin activity, and a high aldosterone/renin ratio?

Treatment of Primary Hyperaldosteronism with Elevated Aldosterone, Low Renin, and High Aldosterone/Renin Ratio

The recommended treatment for hyperaldosteronism with elevated aldosterone, low renin activity, and high aldosterone/renin ratio is mineralocorticoid receptor antagonists (MRAs), specifically spironolactone at a starting dose of 25-100 mg daily, which can be titrated up to 400 mg daily as needed. 1

Diagnostic Confirmation

Before initiating treatment, it's important to confirm the diagnosis:

1. Confirmatory testing: After a positive screening with high aldosterone/renin ratio (>30), perform one of the following confirmatory tests 2, 3:

   • Intravenous saline suppression test
   • Oral salt-loading test with 24-hour urine aldosterone
   • Fludrocortisone suppression test

2. Imaging: Obtain a non-contrast CT scan of the adrenal glands to identify potential adenomas 3

3. Adrenal vein sampling (AVS): This is the gold standard to distinguish between unilateral and bilateral disease, particularly important in patients >40 years old or with normal-appearing adrenal glands on imaging 3

Treatment Algorithm

For Unilateral Disease (Aldosterone-Producing Adenoma)

• First-line treatment: Laparoscopic unilateral adrenalectomy 2

  • Can improve BP control in nearly 100% of patients
  • Completely cures hypertension in approximately 50% of patients
  • Resolves hypokalemia and improves cardiac and kidney function

• Pre-operative management: Spironolactone 100-400 mg daily to prepare for surgery 1

For Bilateral Disease (Idiopathic Hyperaldosteronism) or Non-Surgical Candidates

• First-line treatment: Mineralocorticoid receptor antagonists 2, 3

  • Spironolactone: Start at 25-100 mg daily, can be titrated up to 400 mg daily 1
  • Eplerenone: Alternative option (50-100 mg daily) with fewer sexual side effects 4

• Additional medications if BP control is inadequate with MRAs alone 5:

  • Potassium-sparing diuretics (amiloride or triamterene)
  • Calcium channel blockers
  • ACE inhibitors or angiotensin II receptor blockers

Monitoring and Follow-up

• Regular monitoring of:

  • Blood pressure
  • Serum potassium levels
  • Renal function (especially when starting treatment)
  • Signs of cardiovascular damage

• For patients on spironolactone, monitor for side effects:

  • Gynecomastia and decreased libido in men
  • Menstrual irregularities in women
  • Hyperkalemia, especially in patients with reduced renal function

Common Pitfalls to Avoid

1. Failing to distinguish between unilateral and bilateral disease before deciding on surgical vs. medical management 3

2. Inadequate dosing of MRAs: Many patients require higher doses of spironolactone (100-400 mg daily) for effective control of hyperaldosteronism 1

3. Not monitoring for hyperkalemia, especially in patients with reduced renal function or those taking other potassium-sparing medications

4. Overlooking the need for long-term treatment in bilateral disease or non-surgical candidates, as hyperaldosteronism is a chronic condition requiring ongoing management 3

5. Neglecting to address cardiovascular risk factors, as patients with primary aldosteronism have higher rates of cardiovascular complications compared to those with essential hypertension 2, 6

The evidence strongly supports that proper treatment of primary hyperaldosteronism, whether through surgery for unilateral disease or MRAs for bilateral disease, significantly reduces morbidity and mortality by controlling blood pressure, normalizing potassium levels, and reversing target organ damage 3, 6.