What is the treatment for a patient diagnosed with primary aldosteronism?

Treatment of Primary Aldosteronism

For unilateral primary aldosteronism, laparoscopic unilateral adrenalectomy is the definitive treatment, improving blood pressure in virtually 100% of patients and curing hypertension in approximately 38-50% of cases; for bilateral disease or patients unsuitable for surgery, lifelong treatment with spironolactone or eplerenone is the cornerstone of therapy. 1, 2

Determining Treatment Approach: Unilateral vs. Bilateral Disease

The critical first step after confirming primary aldosteronism is determining laterality, as this dictates whether the patient is a surgical candidate or requires lifelong medical therapy. 1

Imaging and Lateralization

• Obtain a non-contrast CT scan of the adrenal glands as initial imaging to identify unilateral adenoma versus bilateral hyperplasia. 3
• Adrenal venous sampling (AVS) is mandatory before offering adrenalectomy to distinguish unilateral from bilateral disease, except in patients <40 years when imaging shows a single affected gland (bilateral hyperplasia is rare in this population). 3
• CT findings alone are insufficient for treatment decisions, as adenomas on imaging can represent hyperplasia and false positives are common due to nodular hyperplasia. 3

Surgical Treatment for Unilateral Disease

Laparoscopic unilateral adrenalectomy is the treatment of choice for unilateral aldosterone production. 1

Expected Surgical Outcomes

• 95-99% of patients achieve biochemical cure (resolution of autonomous aldosterone secretion and hypokalemia). 2
• Complete clinical success (cure of hypertension without medications) occurs in approximately 38-50% of patients. 1, 2
• Blood pressure improves in virtually 100% of patients, even those not achieving complete cure. 1
• Surgical patients require significantly shorter follow-up (mean 6.5 months vs 13.4 months for medical therapy) and can be discharged to community care more quickly. 2

Additional Benefits of Surgery

• Resolves hypokalemia completely. 1
• Lowers blood pressure and reduces the number of antihypertensive medications required. 1
• Improves parameters of impaired cardiac and kidney function. 1
• Reverses left ventricular hypertrophy. 1

Medical Treatment for Bilateral Disease or Non-Surgical Candidates

For patients with bilateral aldosterone hypersecretion or those unsuitable for surgery, spironolactone or eplerenone is the agent of choice. 1, 4

Spironolactone Dosing

• For primary hyperaldosteronism, administer spironolactone 100-400 mg daily in preparation for surgery or as long-term maintenance therapy at the lowest effective dosage. 4
• Start with 100 mg daily and titrate to maintain a high-normal serum potassium concentration without oral potassium supplements. 3, 5
• Doses can be administered in single or divided doses. 4

Eplerenone as Alternative

• Eplerenone is an alternative option with fewer anti-androgenic side effects compared to spironolactone (avoiding gynecomastia). 3, 2
• Eplerenone is less potent than spironolactone and requires twice-daily administration. 3

Adjunctive Medical Therapy

• Combine mineralocorticoid receptor antagonists with a low-sodium diet for optimal blood pressure control. 5
• Additional conventional antihypertensive medications may be required as needed. 6
• Long-acting calcium channel blockers and alpha-receptor antagonists minimally interfere with aldosterone-renin ratio and can be used as adjuncts. 3

Monitoring and Follow-Up

For Medical Therapy

• Monitor serum potassium within 1 week of spironolactone initiation and regularly thereafter. 3
• Risk of hyperkalemia is increased in older patients, those with diabetes, chronic kidney disease, or concomitant use of ACE inhibitors/ARBs/NSAIDs. 3
• Lifelong medication adherence and monitoring for side effects (gynecomastia with spironolactone, hyperkalemia risk) is required. 2

Post-Surgical Monitoring

• Even after successful adrenalectomy, some patients have residual hypertension due to vascular remodeling from delayed diagnosis. 3
• The rate of cure is higher when diagnosis is made early in the disease course. 3
• Ensure adequate blood pressure control and assess for need of continued antihypertensive medications. 3

Special Considerations

Familial Hyperaldosteronism Type 1

• This rare form can be corrected with low-dose dexamethasone, which is free of glucocorticoid effects and safe during pregnancy. 3

Common Pitfalls to Avoid

• Never proceed to surgery based on CT findings alone without adrenal venous sampling (except in patients <40 years with unilateral imaging findings). 3
• Up to 25% of patients might undergo unnecessary adrenalectomy based on CT findings alone. 3
• Do not rely on presence or absence of hypokalemia to guide treatment decisions, as it is absent in approximately 50% of cases. 3

Referral Recommendations

• All patients with confirmed primary aldosteronism should be referred to a hypertension specialist or endocrinologist for subtype determination and treatment planning. 3, 5