What is the treatment for primary aldosteronism?

Treatment of Primary Aldosteronism

The treatment of primary aldosteronism depends on whether the condition is unilateral or bilateral: laparoscopic adrenalectomy is the first-line treatment for unilateral disease, while mineralocorticoid receptor antagonists (MRAs) are the first-line treatment for bilateral disease. 1

Diagnostic Approach Before Treatment

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

1. Screening: Plasma aldosterone:renin activity ratio (ARR) with cutoff >30 and plasma aldosterone ≥10 ng/dL
2. Confirmatory testing: Intravenous saline suppression test or oral salt-loading test
3. Subtype determination: Adrenal vein sampling (AVS) to distinguish unilateral from bilateral disease

Treatment Algorithm

For Unilateral Primary Aldosteronism

• First-line treatment: Laparoscopic adrenalectomy 1
  • Improves blood pressure in virtually 100% of patients
  • Completely cures hypertension in approximately 50% of patients
  • Preoperative preparation: Spironolactone to control hypertension and hypokalemia

For Bilateral Primary Aldosteronism

• First-line treatment: Mineralocorticoid receptor antagonists 1, 2
  • Spironolactone: Starting dose 12.5-25 mg daily, titrated up to 100 mg daily as needed
  • Eplerenone: Alternative when spironolactone side effects occur, 50-100 mg daily

For Non-surgical Candidates with Unilateral Disease

• Long-term maintenance therapy: Spironolactone 100-400 mg daily 2
• Dosage should be individualized to the lowest effective dose

Monitoring Treatment Response

Short-term Monitoring

• Check serum potassium and renal function within 1-2 weeks of starting treatment
• Monitor potassium at 3 days and 1 week after initiating therapy, then monthly for 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

Managing Side Effects of MRAs

• Common side effects: Gynecomastia and breast tenderness in men, menstrual irregularities in women, sexual dysfunction, hyperkalemia 1
• Strategies to minimize side effects:
  • Use lowest effective dose
  • Consider eplerenone for patients experiencing sexual side effects
  • Regular monitoring of potassium levels, especially when combined with ACE inhibitors

Second-line Treatment Options

• If blood pressure is not normalized with MRAs:
  • Add potassium-sparing diuretics (amiloride or triamterene) 3
  • Add calcium channel antagonists 4

Treatment Outcomes

• Medical treatment with MRAs has been shown to be as effective as surgical treatment for controlling hypertension and preventing cardiovascular and renal morbidities in appropriate patients 4, 5
• MRAs effectively correct metabolic abnormalities and subclinical organ damage 5

Important Considerations

• Early diagnosis and treatment are crucial as vascular remodeling from delayed diagnosis may result in residual hypertension even after treatment 1
• Adrenal venous sampling is key for reliable subtype identification but can be bypassed in patients with specific characteristics (e.g., patients younger than 40 years with unilateral adrenal nodule) 1, 6
• Newer non-steroidal MRAs (finerenone, exarenone) and aldosterone synthase inhibitors (baxdrostat) are being tested for primary aldosteronism 1