PROGRESS IN PRIMARY ALDOSTERONISM: Mineralocorticoid antagonist treatment for aldosterone-producing adenoma

Abstract

Mineralocorticoid receptor antagonists have been used in patients with aldosterone-producing adenomas (APAs) as a test designed to predict the blood pressure (BP) outcome of surgery. They are commonly used in patients undergoing adrenalectomy to reduce BP and increase plasma potassium levels during the preoperative period. A small number of studies have compared the effects of surgery and mineralocorticoid antagonists either on BP, on serum potassium levels, or on the incidence of cardiovascular and renal outcomes in patients with primary aldosteronism with or without an APA; these studies found no difference between the two therapeutic options. Mineralocorticoid receptor antagonists can be used as a maintenance treatment for patients with APAs, who are judged to be poor operative risks or who do not want to undergo surgery.

Mineralocorticoid Receptor Blockers and Aldosterone to Renin Ratio: A Randomized Controlled Trial and Observational Data

“…Regarding subtype classification of PA it should also be mentioned that the diagnostic superiority of AVS versus computed tomography (CT) has been recently challenged, thus questioning the necessity of MR blocker discontinuation for differentiating unilateral versus bilateral disease in PA [34]. While this is still a matter of controversy, it should also be acknowledged that the recommended withdrawal time for MR blockers of 4 weeks before carrying out diagnostic evaluation for PA is based on rather limited evidence [1,14]. This issue warrants further studies including investigations to evaluate whether shorter withdrawal periods are also feasible.…”

“…Therefore, the Endocrine Society Clinical Practice Guideline for the management of PA: case detection, diagnosis, and treatment recommends that "mineralocorticoid receptor (MR) antagonists should be withdrawn at least 4 weeks before ARR testing" [1]. While this is the most important recommendation regarding medication use when measuring the ARR, the data on the impact of MR antagonists (e. g., spironolactone and eplerenone) on the ARR and its components plasma aldosterone concentration (PAC) and direct renin concentration (DRC) is sparse [1,7,[14][15][16][17][18][19][20][21][22][23]. Observational studies and pathophysiological considerations suggest that MR blockers and other potassium sparing diuretics (i. e., amiloride and triamterene) may lead to false negative ARR results as they induce volume contraction and sympathetic nervous stimulation leading to higher DRC and thus lower ARR [18,19].…”

Effect of Eplerenone on the Glomerular Filtration Rate (GFR) in Primary Aldosteronism: Sequential Changes in the GFR During Preoperative Eplerenone Treatment to Subsequent Adrenalectomy

“…However, high-dose SPL has many sex hormone-related side effects, such as gynecomastia, often making it difficult for patients to receive the necessary doses of SPL. EPL, another MRA, is a highly selective MRA with few sex hormone-related side effects ( 1 , 11 ). However, clinical data for EPL in the treatment of PA are limited, and few studies-with only small patient populations-have examined the effects of EPL on glomerular hyperfiltration in patients with PA ( 12 , 13 ).…”

A short review of primary aldosteronism in a question and answer fashion

“…Spironolactone is rapidly metabolized in the liver into a number of metabolites including 7a-methylspironolactone and canrenone (Amar et al 2015). Potassium canrenoate, is a water-soluble derivative of spironolactone, sharing the same active metabolite canrenone, but probably has a different pattern of metabolism that avoids the formation of intermediate products with anti-androgenic effects (Armanini et al 1985;Dupont 1985).…”