What are the treatment recommendations for primary aldosteronism?

Treatment Recommendations for Primary Aldosteronism

The treatment of primary aldosteronism should be based on whether the condition is unilateral or bilateral, with laparoscopic adrenalectomy recommended for unilateral disease and mineralocorticoid receptor antagonists for bilateral disease. 1

Diagnostic Approach Before Treatment

1. Screening:

   • Use plasma aldosterone:renin activity ratio (ARR) as the primary screening test 2, 1
   • ARR cutoff value >30 with plasma aldosterone ≥10 ng/dL indicates positive screening 2, 1
   • Ensure patients have:
     • Unrestricted salt intake
     • Normal serum potassium
     • Mineralocorticoid receptor antagonists withdrawn for ≥4 weeks before testing

2. Confirmatory Testing:

   • Perform either intravenous saline suppression test or oral salt-loading test 2

3. Subtype Determination:

   • Adrenal venous sampling (AVS) is the gold standard to determine if aldosterone production is unilateral or bilateral 1
   • Some institutions may exclude AVS in patients <40 years when imaging shows only one affected gland 1

Treatment Algorithm

For Unilateral Disease (Aldosterone-Producing Adenoma)

1. First-line treatment: Laparoscopic adrenalectomy 2, 1

   • Improves blood pressure in virtually 100% of patients
   • Completely cures hypertension in approximately 50% of patients
   • Resolves hypokalemia and improves cardiac and kidney function

2. Pre-operative management:

   • Short-term treatment with spironolactone (100-400 mg daily) in preparation for surgery 3

3. For patients unsuitable for surgery:

   • Long-term mineralocorticoid receptor antagonist therapy at lowest effective dose 3

For Bilateral Disease (Idiopathic Hyperaldosteronism)

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

   • Spironolactone:

     • Starting dose: 12.5-25 mg daily 4
     • Titrate up to 100 mg daily as needed 4
     • FDA label allows doses of 100-400 mg daily for primary hyperaldosteronism 3

   • Eplerenone (alternative, especially if sexual side effects occur):

     • 50-100 mg daily 4
     • Fewer sexual side effects than spironolactone

2. If blood pressure not controlled:

   • Add potassium-sparing diuretics (amiloride or triamterene) 4
   • Add calcium channel antagonists 4

Monitoring and Follow-up

1. Initial monitoring after starting treatment:

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

2. Long-term monitoring:

   • Regular assessment of blood pressure control
   • Periodic measurement of serum potassium and renal function
   • Watch for side effects of MRAs:
     • Gynecomastia and breast tenderness in men
     • Menstrual irregularities in women
     • Sexual dysfunction
     • Hyperkalemia (especially in patients with renal impairment)

Important Considerations and Pitfalls

• Vascular remodeling from delayed diagnosis may result in residual hypertension even after treatment, highlighting the importance of early diagnosis 1

• Don't rely solely on CT imaging for subtype determination; adrenal vein sampling is the gold standard 1

• Treating primary aldosteronism, either by mineralocorticoid receptor antagonists or unilateral adrenalectomy, resolves hypokalemia, lowers BP, reduces antihypertensive medications required, and improves cardiac and kidney function 2

• MRAs have therapeutic values comparable to surgery in the long-term for correcting metabolic abnormalities, subclinical organ damage, and reducing cardiovascular and renal risks 5

• Newer non-steroidal MRAs (finerenone, exarenone) and aldosterone synthase inhibitor (baxdrostat) are being investigated for primary aldosteronism 1

• Primary aldosteronism is underdiagnosed despite affecting approximately 10% of all hypertensive patients and up to 20% of those with resistant hypertension 4, 6