What is the best aldosterone blocker for a patient with hyperaldosteronism (Hyperaldosteronism) symptoms?

Best Aldosterone Blocker for Hyperaldosteronism

Spironolactone is the first-line aldosterone blocker for patients with hyperaldosteronism symptoms, with eplerenone reserved as an alternative for patients who develop intolerable side effects. 1, 2

Treatment Selection Based on Disease Type

Primary Hyperaldosteronism

For bilateral idiopathic hyperaldosteronism (IHA), which represents approximately 50% of primary hyperaldosteronism cases, medical therapy with mineralocorticoid receptor antagonists is the cornerstone of treatment 1:

• Spironolactone 100-400 mg daily is the FDA-approved first-line treatment for long-term maintenance therapy 2
• Start at 100 mg daily (can range from 25-200 mg) and titrate based on blood pressure and potassium response 2
• Spironolactone effectively controls blood pressure and corrects hypokalemia in the majority of cases 3

For unilateral disease (aldosterone-producing adenoma), laparoscopic adrenalectomy is the treatment of choice, but spironolactone 100-400 mg daily is indicated for short-term preoperative management 1, 2

When to Use Eplerenone Instead

Eplerenone 50-100 mg daily (in 1-2 divided doses) should be selected when 4, 1:

• Patient develops gynecomastia, breast tenderness, or sexual dysfunction on spironolactone 4, 5
• Male patients express concern about anti-androgenic side effects 5
• Female patients develop menstrual irregularities on spironolactone 3, 5

The evidence shows eplerenone is equally effective as spironolactone for blood pressure control in IHA, with one randomized trial demonstrating 82.4% vs 76.5% achieving BP <140/90 mmHg respectively (p=1.00) 6. However, eplerenone often requires twice-daily dosing for adequate blood pressure lowering 4.

Critical Safety Monitoring

Before initiating any aldosterone antagonist 4, 1:

• Verify serum potassium ≤5.0 mEq/L 4
• Confirm serum creatinine <2.0-2.5 mg/dL or eGFR >30 mL/min 4, 1
• Discontinue potassium supplements 4

Monitoring schedule 4:

• Check potassium and creatinine at 3 days, 1 week, then monthly for first 3 months 4
• Subsequently monitor every 3 months if stable 4

Common Pitfalls to Avoid

Do not combine aldosterone antagonists with 4, 1:

• Potassium supplements or potassium-sparing diuretics (increased hyperkalemia risk) 4, 1
• ACE inhibitors or ARBs without extremely close monitoring (significantly increased hyperkalemia and renal dysfunction risk) 4
• NSAIDs or COX-2 inhibitors (can precipitate renal dysfunction and hyperkalemia) 4

Dose adjustment for renal impairment 1:

• eGFR 30-50 mL/min: Use with extreme caution, consider lower doses 1
• eGFR <30 mL/min: Avoid use 1

If potassium exceeds 5.5 mEq/L: Discontinue or reduce dose immediately unless patient is on potassium supplementation (which should be stopped first) 4

Why Spironolactone Remains First-Line

Despite eplerenone's superior side effect profile, spironolactone maintains its position as first-line therapy because 2, 3:

• FDA-approved specifically for primary hyperaldosteronism treatment 2
• Decades of clinical experience with proven efficacy 3
• Lower cost and once-daily dosing at therapeutic doses 2
• Broader dose range (100-400 mg) allows more flexible titration 2

The 2017 ACC/AHA guidelines and American College of Cardiology recommendations consistently identify spironolactone as the preferred agent for primary aldosteronism and resistant hypertension, with eplerenone listed as an alternative 4, 1.