What is the medical management of primary aldosteronism for elevated Blood Pressure (BP)?

Medical Management of Primary Aldosteronism for Elevated Blood Pressure

For primary aldosteronism, mineralocorticoid receptor antagonists (MRAs) are the cornerstone of medical management, with spironolactone being the first-line agent at doses of 50-100 mg daily, which can be titrated up to 300-400 mg daily if necessary. 1

Diagnostic Classification and Treatment Approach

• Primary aldosteronism (Conn syndrome) is the most common form of secondary hypertension, with approximately 50% of cases being unilateral (usually aldosterone-producing adenoma) and 50% bilateral (idiopathic hyperaldosteronism) 1
• The management approach depends critically on whether the condition is unilateral or bilateral, determined through adrenal vein sampling or functional imaging with radiolabeled tracers 1
• Unilateral disease is potentially curable with surgery, while bilateral disease requires lifelong medical therapy 1

Medical Management Algorithm

For Bilateral Primary Aldosteronism

1. First-line therapy: Spironolactone

   • Initial dose: 50-100 mg once daily 1, 2
   • Can be titrated up to 300-400 mg daily if necessary 1
   • Most widely available MRA with extensive clinical experience 1
   • FDA-approved for long-term maintenance therapy for bilateral micro or macronodular adrenal hyperplasia 2

2. Alternative MRA: Eplerenone

   • Consider when spironolactone causes unacceptable side effects 1
   • Less potent than spironolactone and requires twice-daily administration 1
   • Advantage: Fewer anti-androgenic side effects (gynaecomastia, erectile dysfunction) 1, 3

3. Monitoring and Dose Adjustment

   • Close monitoring of serum electrolytes and renal function is essential when initiating therapy 3
   • Monitor plasma renin activity and titrate MRA dose to increase renin when hypertension remains uncontrolled 4

For Unilateral Primary Aldosteronism

• Laparoscopic adrenalectomy is the treatment of choice 1
• Medical therapy with MRAs is indicated when:
  • Patient is not a surgical candidate due to age or comorbidities 1
  • Patient declines surgery 1
  • As preoperative treatment 2

For Special Forms of Primary Aldosteronism

• Familial hyperaldosteronism type 1 (glucocorticoid-remediable aldosteronism) can be treated with low-dose dexamethasone 1, 5

Optimizing Treatment Outcomes

• Early diagnosis and treatment improve cure rates and reduce target organ damage 1
• MRAs not only control blood pressure but also reverse aldosterone-specific target organ damage including left ventricular hypertrophy, albuminuria, and carotid intima-media thickness 6
• If blood pressure remains uncontrolled on MRA monotherapy, additional agents may be needed:
  • Potassium-sparing diuretics (amiloride or triamterene) 3
  • Calcium channel blockers 3

Common Pitfalls and Considerations

• Delayed diagnosis can lead to vascular remodeling that affects renal function and may cause residual hypertension even after appropriate treatment 1
• Spironolactone can cause hyperkalemia, especially in patients with reduced renal function - careful monitoring is essential 2
• Anti-androgenic side effects of spironolactone (gynaecomastia, erectile dysfunction) may limit compliance - consider eplerenone in these cases 1, 7
• Newer agents such as non-steroidal MRAs (finerenone and exarenone) and aldosterone synthase inhibitors (baxdrostat) are being investigated but are not yet standard of care 1, 7

Referral Considerations

• Complex cases or rare forms of primary aldosteronism should be referred to specialized hypertension centers 1, 5
• Adrenal venous sampling should be performed at experienced centers to ensure accurate subtype classification 4