What is the management of aldosterone-related disorders?

Management of Aldosterone-Related Disorders

Screening and Diagnosis

Screen all hypertensive patients with resistant hypertension, hypokalemia (spontaneous or diuretic-induced), incidental adrenal mass, family history of early-onset hypertension, or stroke before age 40 using the plasma aldosterone-to-renin ratio. 1

Diagnostic Algorithm

• Use plasma aldosterone:renin activity ratio as the screening test, with a cutoff value of 30 (when aldosterone is in ng/dL and renin activity in ng/mL/h) 1
• Ensure plasma aldosterone concentration is at least 10 ng/dL to interpret a positive test, as very low renin levels can falsely elevate the ratio 1
• Withdraw mineralocorticoid receptor antagonists for at least 4 weeks before testing, maintain unrestricted salt intake, and normalize serum potassium 1
• Perform confirmatory testing (intravenous saline suppression or oral salt-loading test) after positive screening 1
• Refer to hypertension specialist or endocrinologist for positive screening results 1

Common Pitfall

Hypokalemia is absent in the majority of primary aldosteronism cases and has low negative predictive value—do not exclude the diagnosis based on normal potassium levels. 1, 2

Treatment Based on Disease Subtype

Unilateral Disease (Aldosterone-Producing Adenoma)

Perform laparoscopic unilateral adrenalectomy as definitive treatment, which improves blood pressure in virtually 100% of patients and cures hypertension in approximately 50%. 1, 2

• Obtain adrenal venous sampling to confirm lateralization before surgery if the patient is a surgical candidate 1
• For non-surgical candidates, use mineralocorticoid receptor antagonists as described below 2

Bilateral Disease (Idiopathic Hyperaldosteronism)

Initiate spironolactone 100-400 mg daily as first-line medical therapy for bilateral adrenal hyperplasia. 1, 2, 3

• Start with 50-100 mg daily and titrate based on blood pressure response and potassium levels 2, 3
• Maximum dose is 400 mg daily for primary hyperaldosteronism 3
• Switch to eplerenone 50-100 mg daily if patients develop gynecomastia, breast tenderness, or sexual dysfunction on spironolactone 2

Familial Hyperaldosteronism Type 1 (Glucocorticoid-Remediable)

Treat with low-dose dexamethasone rather than mineralocorticoid receptor antagonists. 1, 2

Medication Management and Safety

Pre-Treatment Requirements

Before initiating any aldosterone antagonist, verify serum potassium ≤5.0 mEq/L and confirm serum creatinine <2.0-2.5 mg/dL or eGFR >30 mL/min. 2

• Discontinue all potassium supplements before starting therapy 2
• Avoid combining with potassium-sparing diuretics 2

Monitoring Protocol

Check potassium and creatinine at 3 days, 1 week, then monthly for the first 3 months, and every 3 months thereafter if stable. 2

Critical Drug Interactions to Avoid

Do not combine mineralocorticoid receptor antagonists with:

• ACE inhibitors or ARBs without close monitoring—significantly increases hyperkalemia risk 2
• NSAIDs or COX-2 inhibitors—increases risk of hyperkalemia and renal dysfunction 2
• Potassium supplements or potassium-sparing diuretics—causes dangerous hyperkalemia 2

Dose Adjustments for Renal Dysfunction

Use caution with eGFR <45 mL/min and consider dose reduction or increased monitoring frequency. 2

Critical Timing Consideration

Delayed diagnosis and treatment leads to irreversible vascular remodeling, resulting in persistent hypertension even after appropriate treatment—early identification and intervention are essential to prevent permanent cardiovascular and renal damage. 2