A 45-year-old man comes to the physician for follow-up after a recent emergency department visit for abdominal pain. The pain subsided with analgesics. However, he was found to have elevated blood pressure and an incidental right adrenal mass on abdominal imaging. The patient has no prior abnormal findings. He has no symptoms except mild headache, which he attributes to stress at work. He does not use tobacco, alcohol, or illicit drugs. The patient's blood pressure today is 160/94 mm Hg. Serum potassium is 3.0 mEq/L and sodium is 146 mEq/L. Further workup shows a plasma aldosterone/plasma renin activity ratio of 45. He refuses to undergo surgery for removal of the adrenal mass. Which of the following is the best initial therapy for this patient?

Question

A 45-year-old man comes to the physician for follow-up after a recent emergency department visit for abdominal pain.  The pain subsided with analgesics.  However, he was found to have elevated blood pressure and an incidental right adrenal mass on abdominal imaging.  The patient has no prior abnormal findings.  He has no symptoms except mild headache, which he attributes to stress at work.  He does not use tobacco, alcohol, or illicit drugs.  The patient's blood pressure today is 160/94 mm Hg.  Serum potassium is 3.0 mEq/L and sodium is 146 mEq/L.  Further workup shows a plasma aldosterone/plasma renin activity ratio of 45.  He refuses to undergo surgery for removal of the adrenal mass.  Which of the following is the best initial therapy for this patient?

Quizplus · Accepted Answer

11ec25c8_d3b0_d130_bc81_9196aa51c09d_MD0003_00 This patient's presentation of hypertension, hypokalemia, and computed tomography (CT) scan showing an adrenal mass is consistent with primary hyperaldosteronism. The condition is usually due to an adrenal adenoma or bilateral adrenal hyperplasia. Diagnosis is suggested by elevated plasma aldosterone concentration with plasma aldosterone to renin ratio >20. The elevated aldosterone leads directly to decreased renin through a feedback inhibition. Adrenal suppression testing after oral saline load can confirm the diagnosis. Adrenal imaging with CT scan and adrenal venous sampling can usually distinguish between unilateral adrenal adenoma and bilateral adrenal hyperplasia. Surgery is preferred for unilateral adrenal adenoma. Medical therapy is recommended for patients with bilateral adrenal hyperplasia or with unilateral adrenal adenoma who refuse surgery or are poor surgical candidates. Spironolactone is an aldosterone antagonist and the preferred initial medical therapy. However, spironolactone is also a progesterone and androgen receptor antagonist that can cause significant side effects in both men (eg, decreased libido, gynecomastia) and women (eg, breast tenderness, menstrual irregularities). Eplerenone is a very selective mineralocorticoid antagonist with a very low affinity for progesterone or androgen receptors. It has fewer endocrine side effects and is an alternate therapy. (Choices A and E) Some patients may still have persistent hypertension despite aldosterone antagonist therapy. Additional antihypertensives such as thiazide diuretics (eg, chlorthalidone) or angiotensin-converting-enzyme inhibitors (eg, ramipril) are usually recommended for blood pressure control in these patients. However, they are not the best initial therapy. (Choices B, D, and F) Clonidine, hydralazine, and verapamil are not initially preferred as medical therapy for primary hyperaldosteronism. They are 2nd- or 3rd-line antihypertensives that may be used in some patients with persistent hypertension despite adequate 1st-line medical therapy. Educational objective: Primary hyperaldosteronism is usually due to an adrenal adenoma or bilateral adrenal hyperplasia. Surgery is preferred for unilateral adrenal adenoma. Medical therapy with aldosterone antagonists (eg, spironolactone, eplerenone) is recommended for patients with bilateral adrenal hyperplasia or with unilateral adrenal adenoma who either refuse surgery or are poor surgical candidates. References: Primary aldosteronism: diagnostic and treatment strategies. (http://www.ncbi.nlm.nih.gov/pubmed/16932426) A double-blind, randomized study comparing the antihypertensive effect of eplerenone and spironolactone in patients with hypertension and evidence of primary aldosteronism. (http://www.ncbi.nlm.nih.gov/pubmed/21451421)

A 45-Year-Old Man Comes to the Physician for Follow-Up After