Real-World Effectiveness of Mineralocorticoid Receptor Antagonists in Primary Aldosteronism

Yuta Tezuka, Adina F Turcu, Yuta Tezuka, Adina F Turcu

Abstract

Objective: To investigate how often target renin is pursued and achieved in patients with primary aldosteronism (PA) and other low renin hypertension (LRH) treated with mineralocorticoid receptor antagonists (MRAs), as reversal of renin suppression was shown to circumvent the enhanced cardiovascular and renal morbidity and mortality in these patients.

Patients and methods: We conducted a retrospective cohort study of patients with PA and LRH treated with MRAs in an academic outpatient practice from January 1, 2000, through May 31, 2020.

Results: Of 30,777 patients with hypertension treated with MRAs, only 7.3% were evaluated for PA. 163 patients (123 with PA) had renin followed after MRA initiation. After a median follow-up of 124 [interquartile range, 65-335] days, 70 patients (43%) no longer had renin suppression at the last visit. The proportion of those who achieved target renin was higher in LRH than in PA (53% vs. 40%). Lower baseline serum potassium, lower MRA doses, and beta-blocker use were independently associated with lower odds of achieving target renin in PA, while male sex was associated with target renin in LRH. Overall, 50 patients (30.7%) had 55 adverse events, all from spironolactone, and 26 patients (52%) were switched to eplerenone or had a spironolactone dose reduction.

Conclusion: Despite evidence that reversal of renin suppression confers cardio-renal protection in patients with PA and LRH, renin targets are followed in very few and are achieved in under half of such patients seen in an academic setting, with possibly even lower rates in community practices.

Keywords: adrenal; adrenal cortex; adrenal disorders; aldosterone; hypertension; mineralocorticoid receptor (MR) antagonist; primary aldosteronism; renin.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2021 Tezuka and Turcu.

Figures

Figure 1
Figure 1
Selection of study participants. MRA, mineralocorticoid receptor antagonist; PA, primary aldosteronism.
Figure 2
Figure 2
Cumulative rates of target renin achievement during MRA therapy. MRA, mineralocorticoid receptor antagonist; PA, primary aldosteronism; LRH, low-renin essential hypertension; W, weeks; M, months; Y, year. Changes of target renin rates in all participants (A, n=163), PA patients (B, n=123), and LRH patients (C, n=40) during follow-up after initiation of MRA. Patients who reached target renin are shown in black bars, those who continued to have suppressed renin in white bars, and those in whom renin was not assessed in grey bars.

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