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Treatment of primary hyperaldosteronism
Last reviewed: 20.10.2021
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With the expansion of knowledge about the different pathways of the pathogenesis of primary hyperaldosteronism and the variability of its clinical forms, the therapeutic tactics also changed.
With aldosterome, only surgical treatment. Idiopathic and indeterminate aldosteronism create an alternative situation in which the feasibility of surgical treatment is challenged by many authors. Even the total adrenalectomy of one adrenal gland and the subtotal of the other, eliminating hypokalemia in 60% of patients, does not give a significant hypotensive effect. At the same time, spironolactones against the background of low salt diet and the addition of potassium chloride normalize the level of potassium, reduce arterial hypertension. In addition, spironolactones not only eliminate the effect of aldosterone on renal and other potassium-secreting levels, but also inhibit the biosynthesis of aldosterone in the adrenal glands. Almost 40% of patients have surgical treatment that is fully effective and justified. Arguments in its favor may be the high cost of lifelong use of large doses of spironolactones (up to 400 mg daily), while in men the incidence of impotence and gynecomastia is due to the antiandrogenic effect of spironolactones having a structure close to steroids and suppressing testosterone synthesis according to the principle of competitive antagonism.
The effectiveness of surgical treatment and the restoration of the disturbed metabolic balance to a certain extent depend on the duration of the disease, the age of the patients and the degree of development of secondary vascular complications.
However, after successful removal of aldosterome, hypertension remains in 25% of patients, and in 40% - recurs after 10 years.
With a solid tumor size, a long duration of the disease with intensive metabolic disorders, hypodalysteronism episodes (weakness, propensity to syncope, hyponatremia, hyperkalemia) may appear some time after the operation.
Surgical treatment should be preceded by long-term treatment with spironolactones (1-3 months at 200-400 mg daily) to normalize the level of electrolytes and eliminate hypertension. Along with them, or instead of them, potassium-sparing diuretics (triampur, amiloride) can be used.
The hypotensive effect of spironolactones in primary aldosteronism is potentiated by captopril.
Prolonged administration of spironolactones somewhat activates the suppressed renin-angiotensin system, especially with bilateral hyperplasia, and thus preventive maintenance of postoperative hypoaldosteronism.