Dual Therapy with Aldosterone Receptor Antagonists in Patients with Primary Hyperaldosteronism (PA) and Intolerance to High Dose Spironoloactone

Presentation Number: SAT-69
Date of Presentation: June 15th, 2013

Rodis Paparodis*1, Subarna Mani Dhital2 and Yoram Shenker3
1University of Wisconsin - Madison, Madison, WI, 2Patan Academy of Health Sciences, Kathmandu, Nepal, 3University of Wisconsin, Madison, WI


Background: Aldosterone receptor antagonists (ARA) are the mainstay of medical management of aldosterone excess syndromes. Spironolactone (SPR) is an effective ARA, but causes painful gynecomastia in more than 50% of patients when doses >100mg daily are used. Eplerenone (EPL) is less potent and causes gynecomastia in <5%. Combination therapy of EPL and low dose SPR could be beneficial in patients intolerant of high dose SPR.

Cases presentation: We present two patients with PA treated with a combination of high dose EPL and low dose SPR, after they developed painful gynecomastia from high dose SPR.

1. A 60 year old man with HTN since the age of 46, on 4 medications, found to have PA due to bilateral hypersecretion of aldosterone by adrenal vein sampling (AVS). He was placed on SPR 100mg BID and developed painful gynecomastia. This was changed to EPL 50mg BID, but was inadequate to control the HTN or hypokalemia. SPR 25mg BID was added; the HTN got well controlled and the hypokalemia resolved. The latest K level off supplements was 3.8 mmol/L. He complains of rare breast discomfort, which is not serious enough to affect compliance.

2. A 71 year old man with resistant HTN and hypokalemia diagnosed with PA at the age of 55, with normal CT of the adrenal glands. He was placed on SPR 50mg BID, but developed painful gynecomastia and discontinued it. Subsequently he was placed on 5 antihypertensive medications and 80 meq of KCl daily, without controlling the HTN or hypokalemia. Follow up CT abdomen revealed a 1.2cm left adrenal adenoma, but due to patient preference, AVS was not performed. EPL was started at 50 mg BID, and all antihypertensives were discontinued, but the BP rose and the K dropped to 2.9 mmol/L. SPR was added at 25 mg BID, with prompt improvement in the blood pressure and K. Currently he is only on two additional antihypertensives. He denies any painful gynecomastia.

Conclusions: Spironolactone is the first line of therapy for medical management of aldosterone excess, but is associated with high incidence of painful gynecomastia. Eplerenone alone is frequently inadequate to control the mineralocorticoid excess, due to its low potency. The addition of low dose spironolactone in this patient population could decrease the number of medications needed to control the HTN and hypokalemia, without the onset of its common adverse effects, such as painful gynecomastia.


Nothing to Disclose: RP, SMD, YS