Primary Aldosteronism Guidelines

Updated: Aug 10, 2021
  • Author: Gabriel I Uwaifo, MD; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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Guidelines Summary

A series of recommendations on the management of primary aldosteronism were developed by the French Endocrinology Society (SFE), the French Hypertension Society (SFHTA), and the Francophone Endocrine Surgery Association (AFCE). [56, 57, 58, 59, 60, 61, 62, 63] They include a recommendation to screen for primary aldosteronism in patients with any of the following:

  • Severe hypertension (systolic blood pressure of 180 mm Hg or greater or diastolic blood pressure of 110 mm Hg or greater)
  • Resistant hypertension (systolic blood pressure of 140 mm Hg or greater or diastolic blood pressure of 90 mm Hg or above, even after the use of at least three antihypertensive agents, including a thiazide diuretic)
  • Hypokalemia-associated hypertension (either spontaneous or diuretic associated)
  • Hypertension or hypokalemia related to an adrenal incidentaloma

Regarding surgery, the recommendations state that laparoscopic adrenalectomy should be used for patients with lateralized primary aldosteronism who are candidates for surgery. In terms of medical treatment, the use of amiloride is recommended for patients with spironolactone intolerance, while eplerenone is suggested as another alternative in cases of spironolactone intolerance or if amiloride does not sufficiently control hypertension.

In a 2016 update to its 2008 clinical practice guidelines for the diagnosis and treatment of primary aldosteronism, the Endocrine Society included the following recommendations [64, 65] :

  • Screening for the condition in subjects with sustained blood pressure above 150/100 mm Hg, as found on each of three measurements obtained on different days, as well as in patients with hypertension (blood pressure >140/90 mm Hg) resistant to three conventional antihypertensive drugs (including a diuretic) or with controlled blood pressure (< 140/90 mm Hg) on four or more antihypertensive drugs, with hypertension and spontaneous or diuretic-induced hypokalemia, with hypertension and adrenal incidentaloma, with hypertension and sleep apnea, or with hypertension and a family history of early onset hypertension or cerebrovascular accident at a young age (< 40 years); screening should also be performed in all hypertensive first-degree relatives of patients with primary aldosteronism
  • The use of the plasma aldosterone/renin ratio for detection of possible primary aldosteronism in the above patient groups
  • The use of one or more confirmatory tests in patients with a positive plasma aldosterone/renin ratio to definitively confirm or exclude the diagnosis
  • The use of adrenal CT scanning in all patients with primary aldosteronism to exclude large masses that may represent adrenocortical carcinoma and to assist the interventional radiologist and surgeon where anatomically appropriate
  • When surgical treatment is feasible and desired by the patient, the use of adrenal venous sampling to make the distinction between unilateral and bilateral adrenal disease
  • The use of genetic testing for familial hyperaldosteronism type 1 in patients in whom the onset of primary aldosteronism is confirmed before age 20 years and in those with a family history of primary aldosteronism or stroke at a young age (< 40 y)
  • The use of unilateral laparoscopic adrenalectomy in patients with documented unilateral primary aldosteronism (ie, aldosterone-producing adenoma or unilateral adrenal hyperplasia), or, in patients who are unable or unwilling to undergo surgery, the administration of medical treatment including a mineralocorticoid receptor antagonist
  • The administration of medical treatment with a mineralocorticoid receptor antagonist in patients with primary aldosteronism due to bilateral adrenal disease
  • In patients with glucocorticoid-remediable aldosteronism, administration of the lowest dose of glucocorticoid to lower adrenocorticotropic hormone and thus normalize blood pressure and potassium levels as the first-line treatment; if blood pressure fails to normalize with glucocorticoid alone, a mineralocorticoid receptor antagonist may be added