What is treatment for aldosteronism

The short version: treatment for aldosteronism depends on whether the excess aldosterone comes from one adrenal gland or both, and the evidence shows surgery outperforms medication for unilateral cases.

For a single aldosterone-producing adenoma, unilateral adrenalectomy is the definitive treatment. A Hong Kong study of 104 patients found that 48.5% were completely cured of hypertension after surgery, and 88.5% improved [4]. A larger series of 376 patients reported a 55% complete cure rate [5]. Another study with a 5-year median follow-up found a 91% biochemical cure rate [6]. The strongest predictors of cure are female sex, hypertension for less than 5 years, and taking 2 or fewer blood pressure drugs before surgery [4]. The surgery itself is safe: a review of 255 LESS (laparoendoscopic single-site) adrenalectomies found shorter hospital stays and less pain than conventional laparoscopic surgery, though no randomized trials exist [7].

For bilateral aldosteronism (idiopathic hyperplasia) or when surgery is not an option, mineralocorticoid receptor antagonists (MRAs) are the medical standard. Spironolactone 25-50 mg daily was superior to other drugs in a randomized trial of 335 patients with resistant hypertension, lowering systolic blood pressure by about 13 mmHg [3]. However, a 2020 study of 89 patients found that MRA therapy achieved target renin levels in fewer than half of patients after one year [1]. Spironolactone can cause gynecomastia and menstrual irregularities; eplerenone is an alternative with fewer sex-hormone side effects but lower potency. A 2024 case report showed that the newer MRA finerenone produced only a partial response in a patient who could not tolerate spironolactone or eplerenone [2].

Newer aldosterone synthase inhibitors (baxdrostat, lorundrostat) are in development. A phase III trial of 1,083 patients found lorundrostat 50 mg daily reduced systolic blood pressure by about 17 mmHg at 6 weeks, with a placebo-adjusted reduction of 9 mmHg [3]. These drugs suppress aldosterone production directly rather than blocking its receptor, and early data suggest they do not affect cortisol levels [3]. They are not yet approved for routine use.

My call: for a confirmed unilateral adenoma, surgery offers the best chance of cure. For bilateral disease or when surgery is declined, an MRA is the standard but often inadequate option. The evidence for medical treatment is weaker than most clinicians admit. Confidence: moderate.