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endo-avoid-aldosterone-suppression-test

Determines when to avoid aldosterone suppression testing in hypertensive patients with a positive PA screen who have normokalemia and suppressed aldosterone below assay‑specific cutoffs (<11 ng/dL immunoassay or <8 ng/dL LC‑MS/MS), indicating low likelihood of primary aldosteronism. Use when a clinician asks whether to skip confirmatory suppression testing based on low pretest probability.

The English summary is being prepared. Showing the original description.

dromlakhani/MD2SKILL
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Avoid aldosterone suppression testing when PA likelihood is low

STEP 1 — Gather Information

  • Confirm positive PA screening (elevated ARR with suppressed renin and inappropriate aldosterone)
  • Measure serum potassium to assess for normokalemia (typically 3.5–5.0 mmol/L)
  • Obtain aldosterone concentration and note assay method (immunoassay vs LC‑MS/MS)

STEP 2 — Rule In / Rule Out

  • Is the patient normokalemic and is aldosterone < 11 ng/dL (immunoassay) or < 8 ng/dL (LC‑MS/MS)?
    • Yes → Proceed to Step 3 (low likelihood)
    • No → Do not avoid testing; consider aldosterone suppression testing if intermediate probability for lateralizing PA and surgical interest

STEP 3 — Classify or Stratify

  • Classify as low likelihood of lateralizing PA when both normokalemia and aldosterone below cutoff are present
  • Otherwise classify as intermediate or high likelihood (requires further testing)

STEP 4 — Decide

  • If low likelihood: avoid aldosterone suppression testing and initiate empiric MRA therapy based on screening results
  • If not low likelihood: proceed to aldosterone suppression testing (or other workup) per guideline

Clinical Guardrails / Mimics / Pitfalls

  • Do not rely solely on hypokalemia; up to 60 % of PA patients are normokalemic
  • Avoid false reassurance: ensure ARR elevation is genuine (exclude spurious aldosterone elevation from medications, posture, or acute stress)
  • Do not use this rule in patients with resistant hypertension, hypokalemia, or overt biochemical evidence of renin‑independent aldosterone production (PRA < 0.2 ng/mL/h or DRC < 2 mU/L with aldosterone > 15 ng/dL immunoassay or > 20 ng/dL LC‑MS/MS)
  • Remember that familial hyperaldosteronism and young‑onset PA (<20 yr) also warrant avoidance of suppression testing via genetic screening, not this rule

Concrete Clinical Example

A 58‑year‑old with hypertension has ARR = 45, renin = 0.3 ng/mL/h, aldosterone = 9 ng/dL by immunoassay, potassium = 4.2 mmol/L. Normokalemic and aldosterone < 11 ng/dL → low likelihood → avoid suppression trial, start spironolactone 25 mg daily.

Source: Primary Aldosteronism: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2025, https://doi.org/10.1210/clinem/dgaf284

TODO: consider adding scripts/calc.py for the endo-avoid-aldosterone-suppression-test calculator

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