What is the management and treatment of primary hyperaldosteronism?

Management and Treatment of Primary Hyperaldosteronism

For primary hyperaldosteronism, treatment should be based on subtype classification, with laparoscopic adrenalectomy for unilateral disease and mineralocorticoid receptor antagonists for bilateral disease. 1, 2

Diagnosis and Classification

• Primary aldosteronism is characterized by excessive and autonomous aldosterone production by the adrenal glands, independent of the renin-angiotensin system 2
• Approximately 50% of cases are unilateral (usually aldosterone-producing adenoma) and 50% are bilateral (idiopathic hyperaldosteronism) 1, 2
• Screening is recommended in patients with resistant hypertension, hypokalemia, incidentally discovered adrenal mass, family history of early-onset hypertension, or stroke at a young age (<40 years) 3, 2
• The plasma aldosterone-to-renin ratio is the recommended screening test 3, 2
• Subtype determination is crucial for treatment selection, with adrenal vein sampling being the gold standard method for distinguishing between unilateral and bilateral disease 1, 4

Treatment Algorithm

For Unilateral Disease (Aldosterone-Producing Adenoma or Unilateral Hyperplasia):

• Laparoscopic unilateral adrenalectomy is the treatment of choice 1, 2
• Benefits of surgical treatment include:
  • Improved blood pressure in nearly 100% of patients 2
  • Complete cure of hypertension in approximately 50% of cases 1, 2
  • Reversal of target organ damage caused by excess aldosterone 1, 5
  • Normalization of the renin-angiotensin-aldosterone system and potassium levels 5

For Bilateral Disease (Idiopathic Hyperaldosteronism):

• Medical therapy with mineralocorticoid receptor antagonists (MRAs) is the cornerstone of treatment 1, 2
• Spironolactone is the first-line treatment:
  • Initial dose: 25-100 mg daily (can be given as single or divided doses) 6
  • Can be titrated up to 300-400 mg/day if necessary 1
  • FDA-approved dosage for primary hyperaldosteronism: 100-400 mg daily 6
• Eplerenone is an alternative MRA with fewer anti-androgenic side effects 7

For Special Situations:

• For patients with discrete aldosterone-producing adenomas who are not surgical candidates:
  • Long-term maintenance therapy with spironolactone 6
• For familial hyperaldosteronism type 1 (glucocorticoid-remediable):
  • Low-dose dexamethasone treatment 1, 8
• For preoperative management:
  • Spironolactone 100-400 mg daily in preparation for surgery 6

Monitoring and Follow-up

• Close monitoring of serum electrolytes and renal function is essential when initiating treatment 1, 7
• Patients should be monitored for potential side effects of spironolactone, including hyperkalemia 6
• Early diagnosis and treatment improve outcomes and reduce complications 1, 9

Common Pitfalls and Caveats

• Hypokalemia is absent in the majority of primary aldosteronism cases and has low negative predictive value for diagnosis 3
• Delayed diagnosis and treatment may lead to irreversible vascular remodeling, resulting in residual hypertension even after appropriate treatment 1
• Adrenal vein sampling is crucial for accurate subtype determination but should be performed in specialized centers 1, 4
• Primary aldosteronism is not a benign form of hypertension; it is associated with increased cardiovascular, renal, and metabolic complications 5, 4

Treatment Outcomes

• Successful treatment reduces cardiovascular morbidity and mortality associated with primary aldosteronism 5, 9
• Targeted treatment mitigates aldosterone-specific target organ damage 4
• With appropriate management, outcomes can be excellent 4