Not all patients with primary aldosteronism requiring medical therapy can receive spironolactone. When a specific contraindication is present, the treatment approach shifts to alternative agents with a different profile.
Primary aldosteronism requiring medical therapy with a contraindication to spironolactone. Recognised contraindications include:
When spironolactone is contraindicated, management relies on alternative classes — including non-spironolactone mineralocorticoid receptor antagonists or epithelial sodium-channel inhibitors. The complete selection criteria, sequencing, and dosing are covered in the full structured protocol.
The recommendation (see Fig. 3) does not apply to clinical conditions in which spironolactone is contraindicated (eg, hyperkalemia, advanced renal impairment, or pregnancy) or if a non-spironolactone MRA were indicated for other non-PA indications (eg, heart failure).
When spironolactone is not tolerated and other MRAs are not available, amiloride may be an alternative therapy in the management of PA.
MRAs with greater mineralocorticoid receptor (MR) specificity and fewer androgen/progesterone receptor-mediated side effects may be preferred.
The primary goal of therapy is control of BP.
The secondary goal of therapy is achievement of normokalemia.
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