From the Guidelines
Management of primary aldosteronism should prioritize a stepwise approach, starting with diagnosis confirmation through biochemical testing and subtype classification, and for unilateral disease, laparoscopic adrenalectomy is the preferred treatment, while for bilateral adrenal hyperplasia or patients who cannot undergo surgery, medical therapy with mineralocorticoid receptor antagonists, such as spironolactone or eplerenone, is the mainstay of treatment. The most recent and highest quality study, 1, published in 2024, provides the most up-to-date guidance on the management of primary aldosteronism.
Diagnosis and Subtype Classification
The diagnosis of primary aldosteronism involves biochemical testing, including the aldosterone:renin activity ratio, which is the most accurate and reliable means of screening for primary aldosteronism, as stated in 1 and 1. The diagnosis generally requires a confirmatory test, such as an intravenous saline suppression test or oral salt-loading test.
Treatment Approach
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, as recommended in 1. For bilateral primary aldosteronism, medical treatment is the mainstay, with mineralocorticoid receptor antagonists (MRAs) being the primary choice. Spironolactone is the most widely available MRA, and its effective dose can be titrated up to 300–400 mg once daily if necessary. Eplerenone is an alternative with fewer anti-androgenic side effects, as noted in 1.
Medical Therapy
- Spironolactone: typically started at 50–100 mg once daily and can be titrated up to 300–400 mg once daily based on blood pressure response and potassium levels.
- Eplerenone: an alternative with fewer anti-androgenic side effects, usually administered at 50-100 mg twice daily.
- Additional antihypertensives may be needed, with calcium channel blockers and ACE inhibitors/ARBs being particularly effective.
Lifestyle Modifications
Dietary sodium restriction to less than 2.4 g daily enhances medication efficacy. Regular monitoring of blood pressure, serum potassium, and renal function is essential, with follow-up every 1-3 months initially, then every 6-12 months once stable. Treatment success is measured by normalization of blood pressure, correction of hypokalemia, and prevention of cardiovascular and renal complications associated with excess aldosterone, as emphasized in 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). 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.
Management of Primary Aldosteronism involves the use of spironolactone tablets. The treatment approach includes:
- Short-term preoperative treatment: 100 mg to 400 mg daily
- Long-term maintenance therapy: at the lowest effective dosage determined for the individual patient, for those who are not candidates for surgery or have bilateral micro or macronodular adrenal hyperplasia 2 2.
From the Research
Management of Primary Aldosteronism
The management of primary aldosteronism involves a multistep process, including diagnosis, confirmatory testing, and subtype differentiation for therapeutic management 3. The goals of treatment are to normalize blood pressure and excessive aldosterone production, reduce associated comorbidities, improve quality of life, and reduce mortality.
Treatment Options
- Unilateral adrenalectomy is the preferred treatment for patients with unilateral primary aldosteronism, offering the possibility of cure 3, 4.
- Mineralocorticoid receptor antagonists are the main treatment for bilateral primary aldosteronism 3, 5, 6.
- Novel therapies, including nonsteroidal mineralocorticoid receptor antagonists and aldosterone synthase inhibitors, are being developed as alternative options for primary aldosteronism treatment 4.
Diagnostic Investigation
- The diagnostic investigation involves a multistep process of screening, confirmatory testing, and subtype differentiation 3.
- Adrenal venous sampling is the key for reliable subtype identification, but can be bypassed in patients with specific characteristics 3.
- The aldosterone-to-renin ratio is the most sensitive screening test for primary aldosteronism 6.
Cardiovascular Risk
- Primary aldosteronism is associated with increased cardiovascular and renal morbidity compared to primary hypertension 4, 7.
- Treatment of primary aldosteronism can reduce cardiovascular morbidity and mortality 4, 7.
- Mineralocorticoid receptor antagonists can reverse left ventricular hypertrophy, albuminuria, and carotid intima-media thickness, but may not eliminate the risk of atrial fibrillation 5.