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Treatment of primary hyperaldosteronism
Last reviewed: 06.07.2025
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As knowledge about the various pathogenesis pathways of primary hyperaldosteronism and the variability of its clinical forms expanded, therapeutic tactics also changed.
In case of aldosteronoma, the treatment is only surgical. Idiopathic and indefinite aldosteronism create an alternative situation, in which the expediency of surgical treatment is disputed by many authors. Even total adrenalectomy of one adrenal gland and 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 a low-salt diet and the addition of potassium chloride normalize the potassium level, reduce arterial hypertension. At the same time, spironolactones not only eliminate the effect of aldosterone at the renal and other potassium-secreting levels, but also inhibit the biosynthesis of aldosterone in the adrenal glands. In almost 40% of patients, surgical treatment is completely effective and justified. Arguments in its favor may include the high cost of lifelong use of large doses of spironolactones (up to 400 mg daily), and in men the frequency of impotence and gynecomastia due to the antiandrogenic effect of spironolactones, which have a structure similar to steroids and suppress testosterone synthesis by the principle of competitive antagonism.
The effectiveness of surgical treatment and restoration of the disturbed metabolic balance depend to a certain extent on the duration of the disease, the age of the patients and the degree of development of secondary vascular complications.
However, even after successful removal of aldosterone, hypertension remains in 25% of patients, and in 40% it recurs after 10 years.
With a solid tumor size, a long duration of the disease with intense metabolic disorders, episodes of hypoaldosteronism (weakness, tendency to faint, hyponatremia, hyperkalemia) may appear some time after the operation.
Surgical treatment should be preceded by long-term treatment with spironolactones (1-3 months, 200-400 mg daily) until electrolyte levels are normalized and hypertension is eliminated. Potassium-sparing diuretics (triampur, amiloride) can be used along with or instead of them.
The hypotensive effect of spironolactones in primary aldosteronism is potentiated by captopril.
Long-term administration of spironolactones somewhat activates the suppressed renin-angiotensin system, especially in bilateral hyperplasia, and thus prevents postoperative hypoaldosteronism.