Treatment of primary aldosteronism

ACE: angiotensin-converting enzyme; ARBs: angiotensin II receptor blockers; ARR: aldosterone-renin ratio; AVS: adrenal vein sampling; HCTZ: hydrochlorothiazide; HTN: hypertension; MRA: mineralocorticoid-receptor antagonist; NSAIDs: nonsteroidal anti-inflammatory drugs; PA: primary aldosteronism.

* Subtype is usually determined with AVS. Unilateral disease can be caused by an aldosterone-producing adenoma (APA) or primary adrenal hyperplasia (PAH). Bilateral disease is due to idiopathic adrenal hyperplasia (IHA).

¶ Preoperative management: Control HTN, and correct hypokalemia with potassium supplements or MRA.

Postoperative management: Stop potassium supplements and MRAs and, if possible, decrease antihypertensive therapy (starting with medications that can contribute to hyperkalemia, eg, ACE inhibitors, ARBs).

Monitor for hyperkalemia: Measure serum potassium during hospitalization and once weekly for 4 weeks after discharge. Follow serial serum creatinine in patients with impaired kidney function preoperatively.

Δ Refer to UpToDate content on diagnosis of primary aldosteronism for discussion of ARR and aldosterone suppression testing.

◊ When starting MRAs, monitor potassium and creatinine first 4 to 6 weeks and after dose increases. Avoid NSAIDs and salicylates, and monitor for side effects (gynecomastia with spironolactone). If blood pressure is not well controlled with monotherapy, add antihypertensive drug: HCTZ or chlorthalidone, or ACE inhibitor.