What is the treatment for hyperaldosteronism?

Treatment of Hyperaldosteronism

For unilateral primary aldosteronism, laparoscopic adrenalectomy is the definitive treatment, curing hypertension in approximately 50% of patients and improving blood pressure in virtually all cases; for bilateral disease or patients unsuitable for surgery, spironolactone (100-400 mg daily) is the first-line medical therapy. 1

Diagnostic Confirmation Before Treatment

Before initiating treatment, confirm the diagnosis and determine laterality:

• Screen with aldosterone-to-renin ratio (ARR): A positive result is ARR ≥30 with plasma aldosterone ≥10 ng/dL 1, 2
• Perform confirmatory testing: Use intravenous saline suppression test or oral salt-loading test to demonstrate autonomous aldosterone secretion 1
• Obtain adrenal CT imaging: Identify potential adenomas and exclude malignancy 3
• Proceed to adrenal venous sampling (AVS): This is mandatory before offering surgery to differentiate unilateral from bilateral disease, except in patients <40 years with a single affected gland on imaging 2, 4

Critical pitfall: Do not proceed to surgery based on CT findings alone—up to 25% of patients might undergo unnecessary adrenalectomy without AVS confirmation 2

Treatment Algorithm Based on Subtype

Unilateral Disease (Aldosterone-Producing Adenoma)

Laparoscopic unilateral adrenalectomy is the treatment of choice 1, 4:

• Improves blood pressure in virtually 100% of patients 1
• Achieves complete cure of hypertension in approximately 50% 1
• Normalizes hypokalemia and reduces antihypertensive medication requirements 1
• Improves cardiac and kidney function parameters 1

For patients who are not surgical candidates, treat with mineralocorticoid receptor antagonists as described below 4

Bilateral Disease (Idiopathic Hyperaldosteronism)

Spironolactone is the first-line medical therapy 1, 4:

• Starting dose: 100 mg daily (FDA-approved dosing for primary hyperaldosteronism is 100-400 mg daily) 5
• Titration: Can increase up to 400 mg daily based on blood pressure response 5, 6
• Alternative dosing from research: Some sources suggest starting at 12.5-25 mg daily and titrating up to 100 mg daily 6

Eplerenone is the preferred alternative for patients who develop anti-androgenic side effects (gynecomastia, breast tenderness, sexual dysfunction) on spironolactone 4:

• Dosing: 50-100 mg daily in 1-2 divided doses 4
• Equal effectiveness to spironolactone for blood pressure control 4
• Fewer sexual side effects due to greater selectivity for mineralocorticoid receptors 4

Special Subtype: Familial Hyperaldosteronism Type 1

Low-dose dexamethasone is the treatment for glucocorticoid-remediable aldosteronism 4

Pre-Treatment Safety Verification

Before initiating any mineralocorticoid receptor antagonist, verify the following 4:

• Serum potassium ≤5.0 mEq/L 4
• Serum creatinine <2.0-2.5 mg/dL or eGFR >30 mL/min 4
• Discontinue all potassium supplements 4

Monitoring During Medical Therapy

Intensive early monitoring is essential 4:

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

Use caution with eGFR <45 mL/min due to increased hyperkalemia risk 4, 3

Critical Drug Interactions to Avoid

Do not combine mineralocorticoid receptor antagonists with 4:

• Potassium supplements or potassium-sparing diuretics (amiloride, triamterene) 4
• ACE inhibitors or ARBs without close monitoring—significantly increases hyperkalemia risk 4
• NSAIDs or COX-2 inhibitors—increases risk of hyperkalemia and renal dysfunction 4

Exception: If blood pressure is not controlled on spironolactone alone, potassium-sparing diuretics (amiloride or triamterene) or calcium channel blockers can be added as second-line agents, but this requires very close electrolyte monitoring 6

Additional Therapy for Inadequate Blood Pressure Control

If spironolactone or eplerenone alone does not normalize blood pressure:

• Add calcium channel antagonists as preferred second-line agents 6
• Consider potassium-sparing diuretics (amiloride or triamterene) with intensive monitoring 6

Outcomes and Prognosis

Both surgical and medical treatment effectively:

• Lower blood pressure and reverse left ventricular hypertrophy 1
• Resolve hypokalemia 1
• Improve impaired cardiac and kidney function parameters 1

Important caveat: Delayed diagnosis and treatment may lead to irreversible vascular remodeling, resulting in residual hypertension even after appropriate treatment 4. Early detection and treatment are therefore critical to prevent permanent cardiovascular and renal damage 4, 7.