What is the medication therapy for hyperaldosteronism?

Medication Therapy for Hyperaldosteronism

The first-line medication therapy for hyperaldosteronism is mineralocorticoid receptor antagonists (MRAs), with spironolactone being the preferred agent at doses of 25-100 mg daily for initial treatment, which can be titrated up to 400 mg daily for long-term management of primary hyperaldosteronism. 1

Treatment Based on Disease Subtype

Unilateral Hyperaldosteronism

• Laparoscopic unilateral adrenalectomy is the treatment of choice for unilateral disease (aldosterone-producing adenoma or unilateral adrenal hyperplasia), which improves blood pressure in virtually 100% of patients and results in complete cure of hypertension in approximately 50% 2
• For patients who are not surgical candidates, medical therapy with MRAs is recommended 2, 3

Bilateral Hyperaldosteronism

• Medical therapy with MRAs is the cornerstone of treatment for bilateral adrenal hyperplasia 2, 3
• Spironolactone is the first-line agent, with an initial dose of 25-100 mg daily that can be titrated up to 400 mg daily as needed 1
• Eplerenone (50-100 mg daily in 1-2 doses) is an alternative MRA with fewer sexual side effects compared to spironolactone 2

Medication Selection and Dosing

Spironolactone

• Initial dosing: 25-100 mg daily (single or divided doses) 1
• Maintenance dosing: Can be titrated up to 400 mg daily for long-term management 1
• Advantages: Most potent MRA, extensive clinical experience, cost-effective 4
• Disadvantages: Endocrine side effects including gynecomastia, decreased libido, and impotence in men; menstrual irregularities in women 5

Eplerenone

• Dosing: 50-100 mg daily in 1-2 divided doses 2
• Advantages: More selective MRA with fewer sexual side effects than spironolactone 6
• Disadvantages: Less potent than spironolactone, often requires twice-daily dosing, more expensive 2, 5

Adjunctive Therapies

• For inadequate blood pressure control with MRAs alone, consider adding:
  • Potassium-sparing diuretics (amiloride or triamterene) 4, 7
  • Calcium channel blockers 7
  • Thiazide diuretics (with careful monitoring for hypokalemia) 6, 7

Monitoring and Follow-up

• Close monitoring of serum potassium and renal function is essential when initiating MRA therapy 4
• Electrolytes should be checked within 1-2 weeks of starting therapy or changing doses 5
• Blood pressure should be monitored regularly to assess treatment efficacy 8

Special Considerations

• For familial hyperaldosteronism type 1 (glucocorticoid-remediable aldosteronism), low-dose dexamethasone is the treatment of choice 9, 3
• Dietary sodium restriction should be implemented in all cases as the deleterious effects of hyperaldosteronism are dependent on salt loading 7
• Early diagnosis and treatment improve outcomes and may prevent irreversible vascular remodeling that can cause residual hypertension even after appropriate treatment 3

Common Pitfalls and Caveats

• Avoid combining MRAs with other potassium-sparing medications or potassium supplements due to increased risk of hyperkalemia 2
• Use MRAs with caution in patients with significant renal dysfunction (eGFR <45 mL/min) 2
• Do not use MRAs in combination with ACE inhibitors or ARBs without careful monitoring due to increased risk of hyperkalemia 2
• Delayed diagnosis and treatment may lead to irreversible target organ damage, including cardiovascular and renal complications 2, 8