What is the treatment for primary hyperaldosteronism (Hyperaldosteronism)?

From the Guidelines

Primary hyperaldosteronism should be treated with mineralocorticoid receptor antagonists (MRAs) as the first-line treatment, with spironolactone being the most widely available option, starting at a dose of 50-100 mg once daily, which can be titrated up to 300-400 mg once daily if necessary, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. The treatment approach for primary hyperaldosteronism depends on the subtype, particularly whether the adrenal lesions are unilateral or bilateral.

• For unilateral primary aldosteronism, surgical removal of the offending adrenal gland is typically considered, unless the patient is older or has co-morbidities of concern, as stated in the 2024 ESC guidelines 1.
• For bilateral primary aldosteronism, medical treatment is the preferred option, with MRAs being the mainstay of treatment, as recommended by the 2024 ESC guidelines 1 and the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. The diagnosis of primary aldosteronism generally requires a confirmatory test, such as the intravenous saline suppression test or oral salt-loading test, and adrenal venous sampling to determine whether the increased aldosterone production is unilateral or bilateral in origin, as outlined in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline 1. It is essential to monitor patients for side effects, including hyperkalemia, gynecomastia (with spironolactone), and renal dysfunction, and to adjust the treatment plan accordingly, as recommended by the 2024 ESC guidelines 1 and the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline 1. Additional antihypertensive medications like calcium channel blockers or ACE inhibitors may be needed to achieve optimal blood pressure control, and dietary sodium restriction (less than 2.4g daily) is also recommended to enhance the effectiveness of medications, as stated in the example answer. Newer agents, such as the non-steroidal MRAs finerenone and exarenone, and the aldosterone synthase inhibitor baxdrostat, are also being tested for treating primary aldosteronism, as mentioned in the 2024 ESC guidelines 1.

From the FDA Drug Label

1. 4 Primary Hyperaldosteronism Spironolactone tablets are indicated in the following settings: Short-term preoperative treatment of patients with primary hyperaldosteronism. Long-term maintenance therapy for patients with discrete aldosterone-producing adrenal adenomas who are not candidates for surgery Long-term maintenance therapy for patients with bilateral micro or macronodular adrenal hyperplasia (idiopathic hyperaldosteronism).
2. 5 Treatment of Primary Hyperaldosteronism Administer spironolactone tablets in doses of 100 mg to 400 mg daily in preparation for surgery. For patients who are considered unsuitable for surgery, spironolactone tablets can be used as long-term maintenance therapy at the lowest effective dosage determined for the individual patient.

Treatment of Primary Hyperaldosteronism:

• Short-term preoperative treatment: Administer spironolactone tablets in doses of 100 mg to 400 mg daily.
• Long-term maintenance therapy: Use spironolactone tablets at the lowest effective dosage determined for the individual patient, for patients with discrete aldosterone-producing adrenal adenomas who are not candidates for surgery or for patients with bilateral micro or macronodular adrenal hyperplasia (idiopathic hyperaldosteronism) 2, 2.

From the Research

Treatment Options for Primary Hyperaldosteronism

• Primary hyperaldosteronism can be treated through surgical or medical means, depending on the underlying cause and patient characteristics 3, 4, 5.
• For patients with aldosterone-producing adenoma or unilateral adrenal hyperplasia, endoscopic adrenalectomy is a viable treatment option that can potentially cure the condition 3, 4.
• Bilateral adrenal hyperplasia, which accounts for approximately two-thirds of primary hyperaldosteronism cases, is typically treated with mineralocorticoid receptor antagonists such as spironolactone or eplerenone 3, 6, 4.

Medical Treatment

• Mineralocorticoid receptor antagonists are the primary pharmaceutical option for managing primary hyperaldosteronism, particularly in patients with bilateral adrenal hyperplasia 6, 7.
• Spironolactone is often started at a dose of 12.5-25mg/day and can be titrated up to 100mg/day, while eplerenone can be started at a dose of 50-100mg/day 3.
• If blood pressure is not normalized with mineralocorticoid receptor antagonists, additional treatment with potassium-sparing diuretics or calcium channel antagonists may be necessary 3.

Considerations for Treatment

• The choice of treatment should take into account the patient's overall health, age, and potential risks associated with surgery or medical therapy 5.
• In some cases, medical treatment may be preferred over surgery, particularly in patients with primary aldosteronism during pregnancy, advanced age, or hereditary forms of the condition 5.
• Regular monitoring of serum electrolyte and creatinine levels is essential when initiating medical treatment for primary hyperaldosteronism 3.