What is the initial treatment approach for a patient diagnosed with Conn's syndrome?

Initial Treatment Approach for Conn's Syndrome

For patients diagnosed with Conn's syndrome (unilateral aldosterone-producing adenoma), laparoscopic adrenalectomy of the affected adrenal gland is the treatment of choice. 1

Diagnostic Confirmation Before Treatment

Before initiating treatment, proper diagnosis must be established through:

• Aldosterone-to-renin ratio (ARR) as the initial screening test 1, 2
• Confirmatory testing to validate the diagnosis 1, 3
• Adrenal imaging (CT or MRI) to locate the adenoma 1, 3
• Selective adrenal vein sampling to differentiate between unilateral and bilateral disease 1, 2
• Functional imaging with radiolabeled tracers as a potential alternative to adrenal vein sampling in some cases 1

Treatment Algorithm

For Unilateral Disease (Conn's Syndrome)

• First-line treatment: Laparoscopic adrenalectomy of the affected adrenal gland 1, 2
  • This is curative in most cases 3
  • Complete adrenalectomy is preferred over adenomectomy or subtotal adrenalectomy 4, 5
  • Laparoscopic approach is currently the gold standard 6

For Bilateral Disease or Contraindications to Surgery

• First-line medical therapy: Mineralocorticoid receptor antagonists (MRAs) 1, 3
  • Spironolactone: Start at 50-100 mg once daily, can be titrated up to 300-400 mg once daily if necessary 1, 3
  • Eplerenone: Alternative with fewer side effects, requires twice-daily administration 1

Monitoring After Treatment Initiation

• For surgical patients:

  • Monitor blood pressure, serum potassium, and aldosterone levels post-surgery 3
  • Assess for resolution of hypertension and hypokalemia 5

• For patients on medical therapy:

  • Close monitoring of serum electrolytes and creatinine, especially when starting medication 3
  • Regular blood pressure monitoring 3

Emerging Treatment Options

• Newer agents under investigation include:
  • Non-steroidal MRAs (finerenone and exarenone) 1
  • Aldosterone synthase inhibitor (baxdrostat) 1

Important Considerations

• Untreated Conn's syndrome is associated with increased cardiovascular risk and comorbidities including type 2 diabetes mellitus 2
• Subtotal adrenalectomy may lead to persistent hyperaldosteronism and is generally not recommended 4, 5
• Medical therapy with MRAs is typically lifelong for patients with bilateral disease or those who cannot undergo surgery 2