What is the initial treatment for hyperaldosteronism?

Initial Treatment for Primary Hyperaldosteronism

The first-line treatment for primary hyperaldosteronism depends on whether the condition is unilateral or bilateral: mineralocorticoid receptor antagonists (spironolactone 25-100 mg daily) for bilateral disease and laparoscopic adrenalectomy for unilateral disease. 1, 2

Diagnostic Approach Before Treatment

Before initiating treatment, proper diagnosis and subtype determination are essential:

1. Screening: Plasma aldosterone-to-renin ratio (ARR) with cutoff value >30 and plasma aldosterone ≥10 ng/dL 1
2. Confirmatory testing: Intravenous saline suppression test or oral salt-loading test 1
3. Subtype determination:
   • Adrenal CT imaging as initial study
   • Adrenal venous sampling to determine if aldosterone production is unilateral or bilateral 1

Treatment Algorithm Based on Subtype

For Bilateral Disease (60% of cases)

1. First-line treatment: Mineralocorticoid receptor antagonists

   • Spironolactone: Start at 12.5-25 mg daily, titrate up to 50-100 mg daily (maximum 400 mg daily) 1, 2
   • Eplerenone: Alternative with fewer sexual side effects, start at 25 mg daily, titrate up to 50-100 mg daily 1, 3

2. Monitoring:

   • Check serum potassium and renal function within 1-2 weeks of starting treatment
   • Monitor potassium at 3 days, 1 week, then monthly for first 3 months 1
   • Regular blood pressure assessment

3. Adjunctive treatments if blood pressure not controlled:

   • Add potassium-sparing diuretics (amiloride or triamterene)
   • Add calcium channel antagonists 3

For Unilateral Disease

1. First-line treatment: Laparoscopic adrenalectomy 1

   • Improves blood pressure in virtually 100% of patients
   • Completely cures hypertension in ~50% of patients

2. Preoperative management:

   • Spironolactone 100-400 mg daily to prepare for surgery 2

3. Post-surgical monitoring:

   • Blood pressure control
   • Serum potassium normalization

For Special Cases

• Glucocorticoid-remediable aldosteronism: Low-dose dexamethasone 1
• Patients unsuitable for surgery: Long-term maintenance with spironolactone at lowest effective dose 2

Important Considerations

Side Effects to Monitor

• Spironolactone:

  • Hyperkalemia (especially with renal impairment or concomitant ACE inhibitors)
  • Gynecomastia and breast tenderness in men
  • Menstrual irregularities in women
  • Sexual dysfunction 1, 4

• Eplerenone:

  • Less sexual side effects than spironolactone
  • Still carries risk of hyperkalemia
  • Less potent than spironolactone, requires twice-daily dosing 1, 4

Contraindications and Cautions

• Reduce or discontinue diuretics if:

  • Serum sodium <125 mmol/L
  • Hyperkalemia develops
  • Acute kidney injury occurs 5

• For patients with cirrhosis, initiate therapy in hospital setting and titrate slowly 2

Treatment Outcomes

• Treating primary aldosteronism with appropriate therapy resolves hypokalemia, lowers blood pressure, reduces antihypertensive medication requirements, and improves cardiac and kidney function 1
• Delayed diagnosis may result in vascular remodeling and residual hypertension even after treatment 1

Emerging Treatments

Newer agents under investigation include:

• Non-steroidal MRAs (finerenone, exarenone)
• Aldosterone synthase inhibitor (baxdrostat) 1

Remember that early diagnosis and appropriate treatment are critical to prevent long-term cardiovascular and renal complications associated with hyperaldosteronism.