Primary hyperaldosteronism medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

The optimal therapy for primary hyperladosteronism depends on the etiology of hyperaldosteronism.

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:

Drug Class	Agents	Mechanism of action	Dosage	Side effects
Mineralocorticoid receptor antagonists	Spironolactone	Competitive binding of receptors at the aldosterone-dependent sodium-potassium exchange site in the distal convoluted renal tubule	12.5 – 25 mg BID Max of 400 mg OD	Digestive: Gastric bleeding, ulceration, gastritis, diarrhea and cramping, nausea, vomiting. Endocrine: Gynecomastia, irregular menses or amenorrhea, postmenopausal bleeding, carcinoma of the breast Hematologic: Agranulocytosis. Hypersensitivity: Fever, urticaria, maculopapular or erythematous cutaneous eruptions, anaphylactic reactions, vasculitis. Hyperkalemia Nervous system /psychiatric: Mental confusion, ataxia, headache, drowsiness, lethargy. Liver / biliary: cholestatic/hepatocellular toxicity Renal: Renal dysfunction (including renal failure).
	Potassium canrenoate	Aldosterone antagonist
	Eplerenone	Selective aldosterone antagonist	50 mg OD	Hyperkalaemia Hypotension Dizziness Altered renal function Increased creatinine concentration
Potassium-sparing diuretics	Amiloride Triamterene
Calcium channel blockers
ACE inhibitors
Angiotensin receptor blockers

• 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.