What is the treatment for hypertension (high blood pressure) caused by adrenal gland disorders?

From the Guidelines

Treatment of high blood pressure caused by adrenal gland disorders, specifically primary aldosteronism, should be based on the most recent guidelines, which recommend surgical removal of the offending adrenal gland for unilateral primary aldosteronism, unless the patient is older or has co-morbidities of concern, and medical treatment with mineralocorticoid receptor antagonists (MRAs) such as spironolactone (50-400 mg daily) or eplerenone for bilateral primary aldosteronism 1. The management of primary aldosteronism depends on its subtype, particularly on adrenal lesions being 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.
• For bilateral primary aldosteronism, medical treatment is currently based on MRAs, among which spironolactone is the most widely available, with an effective dose of 50–100 mg once daily, which can be titrated up to 300–400 mg once daily, if necessary.
• Eplerenone is also used and, despite being less potent than spironolactone and requiring twice-daily administration, it has the advantage of causing less gynaecomastia and erectile dysfunction in men. The diagnosis of primary aldosteronism generally requires a confirmatory test, such as an 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 1. Regular monitoring of blood pressure, electrolytes, and hormone levels is essential throughout treatment. It is also important to note that primary aldosteronism is one of the most frequent disorders that causes secondary hypertension, and patients with primary aldosteronism have a higher risk of target organ damage, including heart failure, stroke, myocardial infarction, atrial fibrillation, and kidney damage, compared to patients with primary hypertension 1.

From the FDA Drug Label

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).

The treatment for high blood pressure caused by the adrenal gland, specifically primary hyperaldosteronism, involves the use of spironolactone.

• The recommended dosage for short-term preoperative treatment is 100 mg to 400 mg daily.
• For long-term maintenance therapy, the dosage should be the lowest effective dosage determined for the individual patient 2.
• It is essential to note that spironolactone can increase serum potassium, and its administration should be carefully managed, especially in patients with renal impairment 2.

From the Research

Treatment Options for BP Caused by Adrenal Gland

• The treatment of hypertension caused by adrenal gland disorders, such as primary aldosteronism, involves the use of specific anti-aldosterone drugs 3.
• Mineralocorticoid receptor (MR) antagonists, such as spironolactone, are highly effective but can cause significant side effects due to limited selectivity for the MR 3.
• Newer agents, such as eplerenone, have been developed to provide higher selectivity for MR antagonists and fewer adverse effects 3.
• Aldosterone synthase inhibitors are also being explored as a potential treatment option, but they can interfere with cortisol synthesis and accumulate mineralocorticoid precursors 3.

Diagnosis and Screening

• The renin/aldosterone ratio is the best test for initial screening of hyperaldosteronism, followed by localization if possible 4.
• Antihypertensive drugs can influence the neurohumoral cardiovascular system and the concentration of hormones involved in blood pressure regulation, which can disturb the differential diagnosis of hypertension 5.
• Beta-blockers and aldosterone antagonists have the strongest impact on the renin-angiotensin system, and calcium channel blockers may be continued during screening for primary aldosteronism 5.

Pathophysiology of Adrenal Hypertension

• Mineralocorticoid hypertension refers to hypertension caused by increased sodium and water retention by the kidney, expansion of the extracellular fluid compartment, and direct effects on the vasculature and CNS 6.
• Primary hyperaldosteronism is the most common form of mineralocorticoid hypertension, and significant advances have been made in understanding its pathogenesis 6.
• The diagnosis of adrenal-dependent hypertension provides clinicians with a unique treatment opportunity, and screening methods for primary aldosteronism are simple and reliable 7.