What is the treatment for primary hyperaldosteronism?

Treatment of Primary Hyperaldosteronism

The treatment for primary hyperaldosteronism depends on whether the condition is unilateral or bilateral, with laparoscopic adrenalectomy recommended for unilateral disease and mineralocorticoid receptor antagonists (MRAs) for bilateral disease. 1

Diagnostic Approach Before Treatment Selection

Before selecting treatment, proper subtype determination is crucial:

1. Initial adrenal CT imaging
2. Adrenal venous sampling to definitively determine if aldosterone production is unilateral or bilateral 1

Treatment Algorithm

For Unilateral Disease (Aldosterone-Producing Adenoma)

• First-line treatment: Laparoscopic adrenalectomy 1
  • Improves blood pressure in virtually 100% of patients
  • Completely cures hypertension in approximately 50% of patients
  • Normalizes the renin-angiotensin-aldosterone system
  • Corrects hypokalemia

For Bilateral Disease (Idiopathic Hyperaldosteronism)

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

  • Spironolactone:

    • Starting dose: 12.5-25 mg daily
    • Titrate up to 50-100 mg daily (or up to 200 mg if necessary)
    • FDA label indicates doses of 100-400 mg daily may be used for primary hyperaldosteronism 2

  • Eplerenone (alternative to spironolactone):

    • Starting dose: 25 mg daily
    • Requires twice-daily dosing
    • Less potent than spironolactone but has fewer sexual side effects 1

Special Cases

• Glucocorticoid-remediable aldosteronism (Type 1): Can be treated with low-dose dexamethasone 1

• Long-term maintenance therapy: For patients unsuitable for surgery, spironolactone can be used at the lowest effective dosage determined for the individual patient 2

Monitoring After Treatment Initiation

• Initial monitoring:

  • Check serum potassium and renal function within 1-2 weeks
  • Monitor potassium at 3 days and 1 week after initiating therapy
  • Then monthly for the first 3 months 1

• Long-term monitoring:

  • Regular assessment of blood pressure control
  • Periodic measurement of serum potassium and renal function
  • Watch for side effects of MRAs 1

Side Effects Management

• Common side effects of MRAs:

  • Gynecomastia and breast tenderness in men
  • Menstrual irregularities in women
  • Sexual dysfunction
  • Hyperkalemia (especially in patients with renal impairment) 1

• Strategies to minimize side effects:

  • Use the lowest effective dose
  • Consider switching to eplerenone for patients experiencing sexual side effects
  • Regular monitoring of potassium levels, especially when combined with ACE inhibitors 1

Clinical Outcomes

Proper treatment significantly reduces cardiovascular and renal complications associated with primary hyperaldosteronism 3. Early diagnosis and treatment are crucial as vascular remodeling from delayed diagnosis may result in residual hypertension even after treatment 1.

Important Considerations

• Adrenal venous sampling is key for reliable subtype identification but can be bypassed in patients with specific characteristics 4
• Prompt diagnosis and targeted treatment strategies mitigate aldosterone-specific target organ damage 4
• Primary aldosteronism is associated with increased cardiovascular morbidity compared to essential hypertension, making proper treatment essential 3
• For patients with unilateral disease, surgery offers the best chance for complete resolution of hypertension and regression of cardiovascular, renal, and metabolic complications 5

Emerging Treatments

Newer non-steroidal MRAs (finerenone, exarenone) and aldosterone synthase inhibitor (baxdrostat) are being developed as alternative options for primary aldosteronism treatment 1, 3.