What is the treatment for hypoaldosteronism and hyperaldosteronism?

Treatment of Hypoaldosteronism and Hyperaldosteronism

Hyperaldosteronism (Primary Aldosteronism)

Diagnostic Subtype Determination

The critical first step is determining whether aldosterone excess is unilateral or bilateral, as this dictates treatment strategy. 1

• Adrenal venous sampling is the gold standard for distinguishing unilateral (aldosterone-producing adenoma) from bilateral disease (idiopathic hyperaldosteronism), with approximately 50% of cases being unilateral and 50% bilateral 1, 2
• Adrenal venous sampling should be performed in specialized centers and can be bypassed only in patients younger than 40 years with imaging showing a single affected gland, as bilateral hyperplasia is rare in this population 1, 3

Treatment Algorithm for Unilateral Disease

Laparoscopic unilateral adrenalectomy is the definitive treatment of choice for unilateral aldosterone-producing adenoma. 1, 2

• Surgery improves blood pressure in virtually 100% of patients and achieves complete cure of hypertension in approximately 50% of cases 1, 4
• Adrenalectomy reverses left ventricular hypertrophy and improves cardiac and renal function parameters 1, 5
• For patients who are not surgical candidates or refuse surgery, proceed to medical therapy with mineralocorticoid receptor antagonists 1, 4

Treatment Algorithm for Bilateral Disease

Mineralocorticoid receptor antagonists (MRAs) are the cornerstone of treatment for bilateral adrenal hyperplasia. 1, 2

First-Line Medical Therapy:

• Spironolactone is the first-line agent, starting at 25-50 mg once daily (FDA-approved starting dose 25-100 mg daily), titrating up to 100-400 mg/day as needed for blood pressure and potassium control 1, 6, 7
• Eplerenone is an alternative MRA with fewer sexual side effects (gynecomastia, decreased libido), dosed at 50-100 mg daily in 1-2 divided doses 4, 7
• Withdraw MRAs for at least 4 weeks before diagnostic testing to avoid false-negative results 1

Monitoring Requirements:

• Close monitoring of serum potassium and creatinine is mandatory when initiating MRA therapy 6, 7
• Use MRAs with extreme caution in patients with eGFR <45-50 mL/min/1.73 m² due to hyperkalemia risk 4, 6

Second-Line Therapy:

• If blood pressure remains uncontrolled on MRAs alone, add potassium-sparing diuretics (amiloride or triamterene) or calcium channel blockers 7

Special Considerations and Pitfalls

Critical medication interactions and contraindications:

• Never combine MRAs with potassium supplements or other potassium-sparing medications without careful monitoring due to severe hyperkalemia risk 4
• Avoid combining MRAs with ACE inhibitors or ARBs without intensive potassium monitoring 4
• Avoid NSAIDs, oral contraceptives, and sympathomimetics during diagnostic workup as they interfere with aldosterone-renin ratio testing 8

Familial hyperaldosteronism type 1 (glucocorticoid-remediable aldosteronism):

• Treat with low-dose dexamethasone rather than surgery or MRAs 2, 4
• Suspect in patients with family history of early-onset hypertension or stroke at young age (<40 years) 1, 8

Treatment Goals Beyond Blood Pressure

The goal is not merely blood pressure normalization but prevention of aldosterone-induced target organ damage. 5, 9, 3

• Primary aldosteronism causes disproportionate cardiovascular damage compared to essential hypertension, including 3.7-fold increased heart failure risk, 4.2-fold increased stroke risk, and 12.1-fold increased atrial fibrillation risk 8
• Early diagnosis and treatment reverse left ventricular hypertrophy, vascular remodeling, and renal damage 1, 5, 10
• Delayed diagnosis leads to irreversible vascular remodeling and persistent hypertension despite treatment 2, 4

---

Hypoaldosteronism

Note: The provided evidence does not contain specific guidelines or high-quality studies addressing hypoaldosteronism treatment. Based on general medical knowledge, hypoaldosteronism typically presents with hyperkalemia and hypotension, and treatment involves:

• Fludrocortisone (mineralocorticoid replacement) for primary adrenal insufficiency
• Sodium supplementation and dietary potassium restriction
• Treatment of underlying cause (e.g., medication adjustment if drug-induced)

However, this question should be answered based on dedicated hypoaldosteronism guidelines or evidence, which were not provided in the current evidence set.