Medical Therapy in Primary Aldosteronism

Fengjie Tang, Lih M Loh, Roger S Foo, Wann J Loh, Dawn S T Lim, Meifen Zhang, Pei T Tan, Du S Swee, Joan Khoo, Donovan Tay, Lynette Lee, Sarah Y Tan, Ling Zhu, Shui B Soh, Eberta Tan, Peng C Kek, Troy H Puar
Journal of the Endocrine Society, Volume 5, Issue 11, November 2021, bvab144
https://doi.org/10.1210/jendso/bvab144

Abstract

Introduction

Patients with primary aldosteronism (PA) have increased cardiovascular risk, and there are concerns about the efficacy of medical therapy.

Objective

We aimed to assess long-term tolerability and efficacy of medical therapy in PA patients.

Methods

We conducted a retrospective study on 201 PA patients treated with medical therapy (spironolactone, eplerenone, or amiloride) from 2000 to 2020 at 2 tertiary centers. Clinical and biochemical control and side effects were assessed.

Results

Among 155 patients on long-term medications, 57.4% achieved blood pressure (BP) <140/90 mmHg, 90.1% achieved normokalemia (48.0% potassium ≥4.3 mmol/L), and 63.2% achieved renin >1 ng/mL/h. Concordance of biochemical control using potassium and renin levels was 49.1%. Side effects were experienced by 52.3% of patients, with 10.3% switching, 22.6% decreasing dose, and 11.0% stopping medications. Risk factors for side effects were spironolactone use, dose ≥ 50 mg, treatment duration ≥1 year, male gender, and unilateral PA. Patients with unilateral PA used higher spironolactone doses vs bilateral (57 vs 50 mg, P < 0.001) and had more side effects (63.2% vs 41.8%, P = 0.008). Forty-six unilateral PA patients who underwent surgery after initial medical therapy experienced improved BP (systolic from 141 to 135 mmHg, P = 0.045; diastolic from 85 to 79 mmHg, P = 0.002).

Conclusion

Dose-dependent side effects limit efficacy of medical therapy in PA. Future prospective studies should assess the best monitoring strategy for biochemical control during long-term medical therapy. For unilateral PA, surgery remains preferable, yielding better control with less long-term side effects.

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