From the Guidelines
Treatment for low renin hypertension should prioritize mineralocorticoid receptor antagonists, such as spironolactone (25-100 mg daily) or eplerenone (25-50 mg daily), as they directly counter aldosterone effects and have been shown to be effective in reducing blood pressure in patients with resistant hypertension 1.
Key Considerations
- First-line options include thiazide diuretics like hydrochlorothiazide (12.5-50 mg daily) or chlorthalidone (12.5-25 mg daily), which reduce blood volume by promoting sodium excretion.
- Calcium channel blockers such as amlodipine (5-10 mg daily) or nifedipine (30-90 mg daily in extended-release form) are also effective.
- Amiloride (5-10 mg daily) may be added for enhanced potassium retention.
- Patients should monitor electrolytes, particularly potassium levels, when using potassium-sparing diuretics.
- Dietary sodium restriction to less than 2.3g daily complements medication therapy.
Rationale
Low renin states often indicate volume expansion or primary aldosteronism, so treatments targeting volume and aldosterone effects are most effective.
- Beta-blockers and ACE inhibitors are generally less effective in these patients as they primarily work through the renin-angiotensin system, which is already suppressed.
- A study published in Circulation found that spironolactone lowered blood pressure on average by an additional 25 mm Hg systolic and 12 mm Hg diastolic in patients with resistant hypertension 1.
- Another study published in Hypertension found that mineralocorticoid receptor antagonists were effective in improving blood pressure in patients with resistant hypertension, with spironolactone being a suitable option due to its once-daily administration and efficacy at low doses 1.
From the FDA Drug Label
In a study in patients with low renin hypertension, blood pressure reductions in Blacks were smaller than those in whites during the initial titration period with eplerenone. The treatment for low renin patients with hypertension includes the use of eplerenone, which has been shown to produce its expected antihypertensive effects when administered concomitantly with other antihypertensive agents, such as:
- ACE inhibitors
- ARB
- calcium channel blockers
- beta-blockers
- hydrochlorothiazide 2
From the Research
Low Renin Patient Treatments
- Low renin hypertension (LRH) requires appropriate diagnosis and treatment, and several studies have investigated the relationship between PRA status and clinical response to different antihypertensive therapies 3.
- Mineralocorticoid receptor antagonists (MRAs) are effective in patients with resistant hypertension and/or primary aldosteronism (PA), and can decrease the rates of positive screening for primary aldosteronism 4.
- The use of MRAs can lead to an increase in renin and potassium levels, and a reduction in the aldosterone to renin ratio, which can affect the diagnostic accuracy of screening tests for primary aldosteronism 5.
- The treatment of low renin hypertension should be based on the pathophysiological background of the condition, and the differential diagnosis of LRH subtypes is essential to address the patient to the proper clinical management 3, 6.
- The concomitant examination of plasma aldosterone levels and plasma potassium is essential to formulate a differential diagnosis in patients with low renin hypertension 6.
Treatment Options
- Mineralocorticoid receptor antagonists (MRAs) can be used to treat patients with primary aldosteronism and low renin hypertension, but their use can affect the diagnostic accuracy of screening tests 4, 5.
- The choice of treatment should be based on the specific characteristics of the patient and the underlying cause of the low renin hypertension 3, 6.
- Beta-blockers and other antihypertensive therapies may also be used to treat low renin hypertension, but their effectiveness may vary depending on the specific subtype of LRH 7.
Diagnostic Approach
- The diagnostic approach to low renin hypertension should include the measurement of plasma renin and aldosterone levels, as well as plasma potassium 6.
- The use of MRAs can affect the diagnostic accuracy of screening tests for primary aldosteronism, and their use should be avoided in patients with hypertension before measurement of renin and aldosterone for screening of primary aldosteronism 5.
- A differential diagnosis of the most common medical conditions manifesting with a clinical phenotype of low renin hypertension is essential to address the patient to the proper clinical management 6.