Bilateral Primary Aldosteronism: Treatment When MRA Dose Escalation Has Not Achieved Blood Pressure Control

Clinical scenario

This protocol addresses individuals with bilateral primary aldosteronism, those with unknown lateralization status, or those with lateralizing primary aldosteronism who decline surgery or are not surgical candidates. Lifelong medical therapy is the established path for this population.

Why this step is reached — previous treatment and its unmet goal

The preceding management step involved escalating the dose of a mineralocorticoid receptor antagonist — spironolactone or eplerenone — at regular intervals, with the aim of achieving renin de-suppression together with control of blood pressure. This protocol is the next step taken when, even after renin de-suppression, blood pressure control remains insufficient.

Current clinical goal

The primary objective at this stage is control of blood pressure.

Target: Blood pressure control

Treatment approach — overview

Once renin de-suppression has been established, this protocol introduces a further antihypertensive measure from outside the MRA class. The complete structured regimen — including the specific agent category and sequencing — is detailed in the full protocol.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1210/clinem/dgaf284

Lifelong medical therapy that includes an MRA is usually offered to individuals with bilateral PA or lateralization status unknown and to those who decline the surgical option or who are not surgical candidates.
Once renin is de-suppressed, and if further BP reduction is required, other non-MRA antihypertensives should be added or uptitrated.
The primary goal of therapy is control of BP.

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