Hypoaldosteronism medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

The mainstay of treatment for hypoaldosteronism depends upon the level of plasma potassium. Prompt ECG is advised in all suspected patients of hypoaldosteronism as hyperkalemia can lead to cardiac conduction defects. Patients with no ECG changes and moderate hyperkalemia (6.5–7.5 mmol/l) require only monitoring. Patients with severe hyperkalemia (>7.5 mmol/l) are treated with fludrocortisone. Depending upon the volume status, patients may be treated with either 0.9% normal saline or furosemide.

Medical Therapy

• Medical therapy for hypoaldosteronism depends upon the age of the patient and other concurrent disorders such as diabetic nephropathy and renal insufficiency.
• Prompt ECG should be obtained in all suspected patients of hypoaldosteronism as hyperkalemia may alter the electrical activity of heart and predispose to cardiac conduction defects.
• Patients with no ECG changes and moderate hyperkalemia (6.5–7.5 mmol/l) require only monitoring potassium concentrations.
  • Drugs promoting hyperkalemia should be avoided, such as β blockers, ACEi, ARB and potassium-sparing diuretics.
  • Reduced dietary intake of potassium.

• Patients with severe hyperkalemia (>7.5 mmol/l) are treated with fludrocortisone 0.05 to 0.1 mg PO qd.
• Depending upon the volume status, patients may be treated with:
  • In hypovolemic patients, normal saline 0.9% is given to restore volume status.
  • In hypervolemic patients (signs of volume overload) or underlying heart failure furosemide 20 to 40 mg qd is given.

Disease Name

Hyporeninemic Hypoaldosteronism: Treatment is aimed at normalizing volume status, plasma potassium and aldosterone levels.

• Thiazide diuretics: Diuretics (furosemide 20 to 40 mg qd) are the first-line therapy for patients with severe hyperkalemia (>7.5 mmol/l) and fluid overload (seen in renal impairment or congestive heart failure). Avoid diuretics in patients with signs of hypotension or volume depletion.
• Patients who cannot tolerate diuretics due to underlying hypotension or volume depletion are treated with:
  • Patients with normal renal function: Sodium bicarbonate (NaHCO3) is the second line therapy and used in patients who cannot tolerate diuretics due to underlying hypotension or volume depletion. In these patients sodium bicarbonate (NaHCO3) can be used to increase distal delivery of bicarbonate anion and increase urinary potassium excretion. Sodium bicarbonate (NaHCO3) also corrects underlying metabolic acidosis.
  • Patient with inadequate renal function: Sodium polystyrene sulfonate is used in patients with underlying renal disease and decreased potassium excretion. 1gm of sodium polystyrene sulfonate can remove upto 1 mEq of potassium.
• Aldosterone analogues are the third line therapy such as fludrocortisone in the dose of 0.1-0.3 mg/day.

Hyperreninemic hypoaldosteronism: Secondary Isolated Hypoaldosteronism also known as hyperreninemic hypoaldosteronism is seen in patients with severe underlying illness such as liver cirrhosis or heart failure.

• The primary focus of the treatment in hyperreninemic hypoaldosteronism is to treat the underlying condition.
• Decreased level of aldosterone in patients of hyperreninemic hypoaldosteronism does not lead to any clinical complications and is therefore seldom treated.

Isolated Hypoaldosteronism: Isolated Hypoaldosteronism from CYP11B2 gene mutation presents in infancy and are treated with 9α-fludrocortisone 0.05 to 0.2 mg daily. In adults treatment is not necessary.

Pseudohypoaldosteronism type I: Patients of pseudohypoaldosteronism are resistant to aldosterone or mineralocorticoid therapy and treatment is based on:

• Correcting the underlying electrolyte abnormalities with sodium chloride (2 to 8 g/day) and cation-exchange resins.
• Thiazide diuretics are used to treat hyperkalemia. In patients with severe hyperkalemia (>7.5 mmol/l) peritoneal dialysis may be done.
• Pseudohypoaldosteronism decreases after few years and the therapy may be discontinued. However, these patients require salt supplementation till first 3-4 years of life.

Primary or secondary adrenal insufficiency: These patients are treated with fludrocortisone and cortisol:

• Fludrocortisone: Use fludrocortisone 0.1 mg PO qd.
  • Reduce dose to 0.05 mg qd if transient hypertension develops.
  • Maintenance dosage range: 0.1 mg 3 times weekly to 0.2 mg daily.
• Cortisone or hydrocortisone: Cortisone 10 to 37.5 mg q12h orally given in 2 divided doses with two-thirds of the total dose given in the morning (around 8 a.m.) and one third in the afternoon (noon to 4 p.m.)

For complete treatment therapy of adrenal insufficiency please click here.