Primary hyperaldosteronism medical therapy: Difference between revisions

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{{Conn syndrome}}
{{Primary hyperaldosteronism}}
{{CMG}}
{{CMG}}; {{AE}}{{HK}}


==Overview==
==Overview==
The optimal therapy for primary hyperladosteronism depends on the etiology of hyperaldosteronism.
The optimal therapy for primary hyperaldosteronism depends on the [[etiology]] of hyperaldosteronism. Medical therapy is indicated for bilateral [[Adrenal gland|adrenal]] [[hyperplasia]], and all ambiguous causes of primary hyperaldosteronism.
==Medical Therapy==
==Medical Therapy==
Medical therapy is indicated for bilateral adrenal hyperplasia and all ambiguous causes of primary hyperaldosteronism. The following agents may be used to medical management of primary hyperaldosteronism:
 
=== Indications ===
Medical therapy is indicated for:
* Bilateral [[Adrenal gland|adrenal]] [[hyperplasia]]
* All ambiguous causes of primary hyperaldosteronism.  
The following agents may be used to medical management of primary hyperaldosteronism:
{| class="wikitable"
{| class="wikitable"
!Drug Class
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Drug Class
!Agents
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Agents
!Mechanism of action
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Mechanism of action
!Dosage
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Dosage
!Side effects
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Side effects
|-
| rowspan="3" |'''[[Mineralocorticoid receptor]] antagonists'''
|[[Spironolactone]]
|
* [[Competitive inhibition|Competitive binding]] of receptors at the [[aldosterone]]-dependent sodium-potassium exchange site in the [[Distal convoluted tubule|distal convoluted renal tubule]]<ref name="pmid978470">{{cite journal |vauthors=Greiner JW, Kramer RE, Jarrell J, Colby HD |title=Mechanism of action of spironolactone on adrenocortical function in guinea pigs |journal=J. Pharmacol. Exp. Ther. |volume=198 |issue=3 |pages=709–15 |year=1976 |pmid=978470 |doi= |url= |issn=}}</ref>
|
* 12.5 – 25 mg PO q12h
* Max of 400 mg PO daily
|
* Digestive: [[Gastrointestinal bleeding|Gastric bleeding]], [[ulceration]], [[gastritis]], [[diarrhea]] and cramping, [[Nausea and vomiting|nausea]], [[vomiting]]
* Endocrine: [[Gynecomastia]], [[Menses|irregular menses]] or [[amenorrhea]], [[postmenopausal bleeding]], [[carcinoma]] of the breast 
* Hematologic: [[Agranulocytosis]]
* Hypersensitivity: [[Fever]], [[urticaria]], [[maculopapular]] or [[erythematous]] [[cutaneous]] eruptions, [[Anaphylactic reaction|anaphylactic reactions]], [[vasculitis]]
* [[Hyperkalemia]]
* [[Nervous system]]/[[Psychiatric disease|psychiatric]]: [[Mental confusion/indecisiveness|Mental confusion]], [[ataxia]], [[headache]], [[drowsiness]], [[lethargy]]
* [[Liver]] / [[biliary]]: [[Cholestatic]]/[[Hepatocellular Disease|hepatocellular]] toxicity
* [[Renal]]: Renal dysfunction (including [[renal failure]])<ref name="urlwww.accessdata.fda.gov">{{cite web |url=https://www.accessdata.fda.gov/drugsatfda_docs/label/2008/012151s062lbl.pdf |title=www.accessdata.fda.gov |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
|-
|[[Potassium canrenoate]]
|
* [[Aldosterone antagonist]]
|
* [[Parenteral|Parenetral]] administration
 
* 200 mg IV daily
* Max of 800 mg daily
|
* [[Hoarseness]]
* Deepening of voice
* [[Hyperkalemia]]
* [[Nausea]]
* [[Vomiting]]
|-
|-
| rowspan="3" |Mineralocorticoid receptor antagonists
|[[Eplerenone]]
|Spironolactone
|
|
* Competitive binding of receptors at the aldosterone-dependent sodium-potassium exchange site in the distal convoluted renal tubule
* Selective [[aldosterone antagonist]]
|50 mg PO daily<ref name="pmid16200104">{{cite journal |vauthors=Craft J |title=Eplerenone (Inspra), a new aldosterone antagonist for the treatment of systemic hypertension and heart failure |journal=Proc (Bayl Univ Med Cent) |volume=17 |issue=2 |pages=217–20 |year=2004 |pmid=16200104 |pmc=1200656 |doi= |url= |issn=}}</ref>
|
|
* 12.5 – 25 mg BID
* [[Hyperkalaemia]]
* Max of 400 mg OD
* [[Hypotension]]
* [[Dizziness]]
* Altered renal function
* Increased [[creatinine]] concentration
|-
|'''[[Potassium-sparing diuretics]]'''
|
|
* Digestive: Gastric bleeding, ulceration, gastritis, diarrhea and cramping, nausea, vomiting.
* [[Amiloride]]
* Endocrine: Gynecomastia, irregular menses or amenorrhea, postmenopausal bleeding, carcinoma of the breast 
* [[Triamterene]]
* Hematologic: Agranulocytosis.  
|
* Hypersensitivity: Fever, urticaria, maculopapular or erythematous cutaneous eruptions, anaphylactic reactions, vasculitis.
* Acts on [[Distal convoluted tubule|distal renal tubule]] where it selectively blocks [[sodium]] transport, leading to inhibition of [[sodium]]-[[potassium]] exchange<ref name="pmid6927605">{{cite journal |vauthors=Vidt DG |title=Mechanism of action, pharmacokinetics, adverse effects, and therapeutic uses of amiloride hydrochloride, a new potassium-sparing diuretic |journal=Pharmacotherapy |volume=1 |issue=3 |pages=179–87 |year=1981 |pmid=6927605 |doi= |url= |issn=}}</ref>
* Hyperkalemia
|
* Nervous system /psychiatric: Mental confusion, ataxia, headache, drowsiness, lethargy.
* Initial dose: 5 mg PO daily
* Liver / biliary: cholestatic/hepatocellular toxicity
* [[Maintenance dose]]: 5-10 mg PO daily<ref name="urlAmiloride Dosage Guide with Precautions - Drugs.com">{{cite web |url=https://www.drugs.com/dosage/amiloride.html |title=Amiloride Dosage Guide with Precautions - Drugs.com |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
* Renal: Renal dysfunction (including renal failure).
|
** [[Nausea]]
** [[Vomiting]]
** Stomach or abdominal pain
** [[Anorexia]]
** [[Bloating]]
** [[Diarrhea]]
** [[Headache]]
** [[Dizziness]]
** [[Skin rash]]
** [[Weakness]]
** [[Fatigue]]
** [[Constipation]]
** [[Muscle cramps]]
** [[Cough]]
** [[Dyspnea]]
|-
|-
|Potassium canrenoate
|'''[[Calcium channel blocker|Calcium channel blockers]]'''
|
|
* Aldosterone antagonist
* [[Amlodipine]]
* [[Nifedipine]]
|
|
* Prevent '''[[calcium]]''' from entering cells of the blood [[Blood vessel|vessel]]<nowiki/> walls, resulting in lower [[blood pressure]]<ref name="pmid3540226">{{cite journal |vauthors=Katz AM |title=Pharmacology and mechanisms of action of calcium-channel blockers |journal=J Clin Hypertens |volume=2 |issue=3 Suppl |pages=28S–37S |year=1986 |pmid=3540226 |doi= |url= |issn=}}</ref>
|
* 5 mg PO daily
* Max of 10 mg PO daily<ref name="urlwww.accessdata.fda.gov2">{{cite web |url=https://www.accessdata.fda.gov/drugsatfda_docs/label/2007/019787s042lbl.pdf |title=www.accessdata.fda.gov |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
|
* [[Edema]]
* [[Flushing]]
* [[Dizziness|Diziness]]
* [[Palpitation|Palpitations]]
* [[Headache]]
* [[Abdominal pain]]
* [[Somnolence]]<ref name="urlwww.accessdata.fda.gov3">{{cite web |url=https://www.accessdata.fda.gov/drugsatfda_docs/label/2007/019787s042lbl.pdf |title=www.accessdata.fda.gov |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
* May mask diagnosis of Conn's syndrome<ref name="pmid10715768">{{cite journal |vauthors=Brown MJ, Hopper RV |title=Calcium-channel blockade can mask the diagnosis of Conn's syndrome |journal=Postgrad Med J |volume=75 |issue=882 |pages=235–6 |year=1999 |pmid=10715768 |pmc=1741191 |doi= |url= |issn=}}</ref>
|-
|'''[[ACE inhibitor|ACE inhibitors]]'''
|
* [[Lisinopril]]
* [[Captopril]]
|
* Inhibits [[angiotensin-converting enzyme]] ([[ACE]]) thereby decreasing levels of [[angiotensin II]] and blocking the release of [[aldosterone]]<ref name="urlwww.accessdata.fda.gov6">{{cite web |url=https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/019777s054lbl.pdf |title=www.accessdata.fda.gov |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
|
* 20mg-40mg PO daily<ref name="urlwww.accessdata.fda.gov4">{{cite web |url=https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/019777s054lbl.pdf |title=www.accessdata.fda.gov |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
|
* [[Cough]]
* Increased [[creatinine]] concentration
* [[Angioedema]]
* [[Hyperkalemia]]
* [[Renal]] impairment if given in bilateral [[renal artery stenosis]]
* [[Agranulocytosis]]<ref name="urlwww.accessdata.fda.gov5">{{cite web |url=https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/019777s054lbl.pdf |title=www.accessdata.fda.gov |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
|-
|'''[[Angiotensin receptor blockers]]'''
|
* [[Losartan]]
* [[Candesartan]]
* [[Valsartan]]
|
* [[Angiotensin II]] inhibition by interacting selectively with the receptor site and blocking it<ref name="pmid10696996">{{cite journal |vauthors=Burnier M, Brunner HR |title=Angiotensin II receptor antagonists |journal=Lancet |volume=355 |issue=9204 |pages=637–45 |year=2000 |pmid=10696996 |doi= |url= |issn=}}</ref> <ref name="pmid162787272">{{cite journal |vauthors=Barreras A, Gurk-Turner C |title=Angiotensin II receptor blockers |journal=Proc (Bayl Univ Med Cent) |volume=16 |issue=1 |pages=123–6 |year=2003 |pmid=16278727 |pmc=1200815 |doi= |url= |issn=}}</ref>
|
* [[Losartan]] 50 mg PO daily<ref name="urlwww.accessdata.fda.gov7">{{cite web |url=https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020386s049lbl.pdf |title=www.accessdata.fda.gov |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
* [[Candesartan]]16 mg PO daily<ref name="urlwww.accessdata.fda.gov8">{{cite web |url=https://www.accessdata.fda.gov/drugsatfda_docs/label/2005/020838s022lbl.pdf |title=www.accessdata.fda.gov |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
* [[Valsartan]] 80mg-160mg PO daily<ref name="urlwww.accessdata.fda.gov9">{{cite web |url=https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/021283s037lbl.pdf |title=www.accessdata.fda.gov |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
|
|
* [[Dizziness]]
* [[Fatigue]]
* [[Diarrhea]]
* [[Dyspepsia]]
* [[Abdominal pain]]
* [[Arthralgia]]
* [[Sinusitis]]<ref name="pmid16278727">{{cite journal |vauthors=Barreras A, Gurk-Turner C |title=Angiotensin II receptor blockers |journal=Proc (Bayl Univ Med Cent) |volume=16 |issue=1 |pages=123–6 |year=2003 |pmid=16278727 |pmc=1200815 |doi= |url= |issn=}}</ref>
|-
|-
|Eplerenone
|'''[[Dexamethasone]] therapy(For familial hyperaldosteronism type I)'''
|[[Dexamethasone]]
|
|
* Selective aldosterone antagonist
|
|
* 0.5mg-0.75mg IV daily
|
|
|}
|}
 
*Spironolactone
*Potassium canrenoate
*Eplerenone
The first two have affinity for androgen and progesterone receptors, causing side effects such as, gynecomastia (6.9% at dose < 50 mg / day and 52% at dose > 150 mg / day),[108] . Spironolacone is used at a starting dose of 12.5 – 25 mg twice daily and increased gradually to a maximum of 400 mg per day. Eplerenone is a selective mineralcorticoid receptor antagonist without antiandrogen and progesterone agonist activity. It is 60% as potent as spironolactone and should be administered twice daily because of its short half life. It has been shown to be as effective as spironolactone.
Potassium-sparing diuretics — amiloride, triamterene. Potassium-sparing diuretics, such as triamterene or amiloride, have been used, although they are usually not as effective as spironolactone
Other anti-hypertensives — calcium channel blockers, ACE inhibitors, angiotensin receptor blockers, and low doses of thiadzides diuretics.


==References==
{{reflist|2}}
{{reflist|2}}
{{WH}}
{{WH}}

Latest revision as of 19:12, 3 November 2017


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]

Overview

The optimal therapy for primary hyperaldosteronism depends on the etiology of hyperaldosteronism. Medical therapy is indicated for bilateral adrenal hyperplasia, and all ambiguous causes of primary hyperaldosteronism.

Medical Therapy

Indications

Medical therapy is indicated for:

The following agents may be used to medical management of primary hyperaldosteronism:

Drug Class Agents Mechanism of action Dosage Side effects
Mineralocorticoid receptor antagonists Spironolactone
  • 12.5 – 25 mg PO q12h
  • Max of 400 mg PO daily
Potassium canrenoate
  • 200 mg IV daily
  • Max of 800 mg daily
Eplerenone 50 mg PO daily[3]
Potassium-sparing diuretics
Calcium channel blockers
  • 5 mg PO daily
  • Max of 10 mg PO daily[7]
ACE inhibitors
  • 20mg-40mg PO daily[11]
Angiotensin receptor blockers
Dexamethasone therapy(For familial hyperaldosteronism type I) Dexamethasone
  • 0.5mg-0.75mg IV daily

References

  1. ↑ Greiner JW, Kramer RE, Jarrell J, Colby HD (1976). "Mechanism of action of spironolactone on adrenocortical function in guinea pigs". J. Pharmacol. Exp. Ther. 198 (3): 709–15. PMID 978470.
  2. ↑ "www.accessdata.fda.gov" (PDF).
  3. ↑ Craft J (2004). "Eplerenone (Inspra), a new aldosterone antagonist for the treatment of systemic hypertension and heart failure". Proc (Bayl Univ Med Cent). 17 (2): 217–20. PMC 1200656. PMID 16200104.
  4. ↑ Vidt DG (1981). "Mechanism of action, pharmacokinetics, adverse effects, and therapeutic uses of amiloride hydrochloride, a new potassium-sparing diuretic". Pharmacotherapy. 1 (3): 179–87. PMID 6927605.
  5. ↑ "Amiloride Dosage Guide with Precautions - Drugs.com".
  6. ↑ Katz AM (1986). "Pharmacology and mechanisms of action of calcium-channel blockers". J Clin Hypertens. 2 (3 Suppl): 28S–37S. PMID 3540226.
  7. ↑ "www.accessdata.fda.gov" (PDF).
  8. ↑ "www.accessdata.fda.gov" (PDF).
  9. ↑ Brown MJ, Hopper RV (1999). "Calcium-channel blockade can mask the diagnosis of Conn's syndrome". Postgrad Med J. 75 (882): 235–6. PMC 1741191. PMID 10715768.
  10. ↑ "www.accessdata.fda.gov" (PDF).
  11. ↑ "www.accessdata.fda.gov" (PDF).
  12. ↑ "www.accessdata.fda.gov" (PDF).
  13. ↑ Burnier M, Brunner HR (2000). "Angiotensin II receptor antagonists". Lancet. 355 (9204): 637–45. PMID 10696996.
  14. ↑ Barreras A, Gurk-Turner C (2003). "Angiotensin II receptor blockers". Proc (Bayl Univ Med Cent). 16 (1): 123–6. PMC 1200815. PMID 16278727.
  15. ↑ "www.accessdata.fda.gov" (PDF).
  16. ↑ "www.accessdata.fda.gov" (PDF).
  17. ↑ "www.accessdata.fda.gov" (PDF).
  18. ↑ Barreras A, Gurk-Turner C (2003). "Angiotensin II receptor blockers". Proc (Bayl Univ Med Cent). 16 (1): 123–6. PMC 1200815. PMID 16278727.

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