What is the treatment for primary hyperaldosteronism (Conn's syndrome)?

From the Guidelines

The primary treatment for unilateral primary hyperaldosteronism is surgical removal of the offending adrenal gland, while bilateral primary hyperaldosteronism requires lifelong medical treatment with mineralocorticoid receptor antagonists (MRAs) such as spironolactone or eplerenone. The management of primary hyperaldosteronism depends on its subtype, particularly on adrenal lesions being unilateral or bilateral 1. 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.

Medical Treatment

For bilateral primary aldosteronism, medical treatment is currently based on MRAs, with spironolactone being the most widely available 1. The effective dose of spironolactone is usually 50–100 mg once daily, which can be titrated up to 300–400 mg once daily if necessary. Eplerenone is also used, despite being less potent than spironolactone and requiring twice-daily administration, it has the advantage of causing less gynaecomastia and erectile dysfunction in men 1.

Key Considerations

• Regular monitoring of blood pressure, serum potassium, and renal function is essential for patients undergoing medical treatment.
• Patients should follow a low-sodium diet to help control blood pressure.
• Potassium supplements may be needed initially until levels normalize with treatment.
• Blood pressure typically improves within 1-2 weeks of starting treatment, but may take 4-8 weeks to reach maximum effect.

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). Administer spironolactone tablets in doses of 100 mg to 400 mg daily in preparation for surgery. For patients who are considered unsuitable for surgery, spironolactone tablets can be used as long-term maintenance therapy at the lowest effective dosage determined for the individual patient.

The treatment for primary hyperaldosteronism includes:

• Short-term preoperative treatment with spironolactone tablets
• Long-term maintenance therapy for patients who are not candidates for surgery, using the lowest effective dosage The recommended dosage for primary hyperaldosteronism is 100 mg to 400 mg daily in preparation for surgery, and the lowest effective dosage for long-term maintenance therapy 2 2.

From the Research

Primary Hyperaldosteronism Treatment Options

• The treatment of primary hyperaldosteronism depends on the underlying cause, with options including surgery and medication 3, 4, 5, 6, 7.
• For patients with aldosterone-producing adenoma and unilateral adrenal hyperplasia, endoscopic adrenalectomy is a viable treatment option, offering the possibility of cure 3, 6, 7.
• Bilateral adrenal hyperplasia, which accounts for approximately two-thirds of primary hyperaldosteronism cases, is typically treated with mineralocorticoid receptor antagonists, such as spironolactone or eplerenone 3, 4, 5, 6, 7.

Medication Treatment

• Mineralocorticoid receptor antagonists are the primary treatment for bilateral adrenal hyperplasia, with spironolactone often started at a dose of 12.5-25mg/day and titrated up to 100mg/day as needed 3.
• Eplerenone is an alternative to spironolactone, with a typical starting dose of 50-100mg/day 3.
• If blood pressure is not normalized with mineralocorticoid receptor antagonists, additional treatment with potassium-sparing diuretics, such as amiloride or triamterene, or calcium channel antagonists may be necessary 3.

Surgical Treatment

• Unilateral laparoscopic adrenalectomy is the preferred treatment for patients with aldosterone-producing adenomas, offering the possibility of cure 6, 7.
• Adrenal venous sampling is a key diagnostic tool for identifying the source of aldosterone excess and guiding treatment decisions, including the decision to proceed with surgery 6, 7.

Treatment Goals

• The primary goals of treatment for primary hyperaldosteronism are to normalize blood pressure, reduce excessive aldosterone production, and mitigate associated comorbidities and target organ damage 4, 5, 6, 7.
• Prompt diagnosis and targeted treatment can significantly improve outcomes and reduce mortality in patients with primary hyperaldosteronism 7.