From the Guidelines
Checking plasma aldosterone concentration (PAC) in patients with glucocorticoid-remediable aldosteronism (GRA) treated with spironolactone is not necessary for routine management. This is because spironolactone works by blocking aldosterone receptors, not reducing aldosterone levels, so PAC values will remain elevated despite effective treatment 1. The focus of clinical monitoring should be on:
- Blood pressure control
- Serum potassium levels
- Renal function These parameters provide more meaningful information about treatment efficacy than aldosterone levels. Spironolactone is typically started at 50-100 mg daily, with dose adjustments based on blood pressure response and potassium levels, as per the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. The persistent elevation of aldosterone in GRA occurs due to a genetic chimeric mutation causing ACTH-dependent aldosterone production, which spironolactone does not correct. If monitoring is needed to assess disease activity, measuring urinary metabolites of aldosterone might be more informative, but this is rarely necessary once effective treatment is established. Regular monitoring of blood pressure, electrolytes, and renal function every 3-6 months is the most practical approach to managing these patients.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Treatment of Primary Aldosteronism
- Primary aldosteronism (PA) is a common cause of secondary hypertension, and its treatment depends on the subtype, either unilateral or bilateral 2, 3.
- For patients with bilateral primary aldosteronism, treatment with mineralocorticoid receptor antagonists (MRAs) such as spironolactone is the main approach 2, 4.
- The goal of treatment is to normalize blood pressure, serum potassium levels, and excessive aldosterone production 3, 5.
Monitoring of Plasma Aldosterone Concentration (PAC)
- In patients with primary aldosteronism treated with spironolactone, monitoring of PAC may not be necessary as the treatment goal is to control blood pressure and serum potassium levels 6.
- Studies have shown that treatment with MRAs such as spironolactone and eplerenone can effectively decrease blood pressure and increase serum potassium levels, regardless of the changes in PAC 6.
- However, monitoring of PAC may still be useful in certain cases, such as in patients with resistant hypertension or those who do not respond to treatment with MRAs 2, 3.
Practical Recommendations
- The treatment of primary aldosteronism should be individualized, taking into account the subtype, severity of hypertension, and presence of hypokalemia 5.
- Regular follow-up is necessary to monitor the effectiveness of treatment and adjust the dosage of MRAs as needed 5.
- Further studies are needed to investigate the long-term effects of MRAs on cardiovascular and renal outcomes in patients with primary aldosteronism 6.