Is Screening for Primary Aldosteronism Always the Best Option?鈥擱eply

Adina F. Turcu; Suranut Charoensri; Linda Bashaw

doi:10.1001/jamainternmed.2024.1455

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Comment & Response

May 13, 2024

Is Screening for Primary Aldosteronism Always the Best Option?鈥擱eply

Adina F.聽Turcu,聽MD, MS¹; 厂耻谤补苍耻迟听颁丑补谤辞别苍蝉谤颈,听惭顿^1,2; 尝颈苍诲补听叠补蝉丑补飞,听笔丑顿³

Author Affiliations Article Information

¹Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor
²Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
³Department of Internal Medicine, University of Michigan, Ann Arbor

JAMA Intern Med. 2024;184(7):849-850. doi:10.1001/jamainternmed.2024.1455

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In Reply We appreciate the perspective from Boulestreau and Couffinhal on our recent initiative to enhance screening for primary aldosteronism (PA) by leveraging electronic health records capabilities. We designed and implemented an advisory that identifies PA screening candidates and assists clinicians with test ordering and interpretation.¹ Boulestreau and Couffinhal suggest empirical use of mineralocorticoid receptor antagonists (MRA) to treat patients with possible PA as a more pragmatic alternative to PA screening.

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May 14, 2024

Not only Primary Aldosteronism: Look for a Liddle phenotype as well

J David Spence, M.D. | Stroke Prevention & Atherosclerosis Research Centre, Robarts Researh Institute, Western University, London, Canada

To be sure, it is important to investigate the cause of resistant hypertension by measuring plasma renin activity (PRA),and aldosterone, so that the appropriate therapy can be implemented. Primary aldosteronism (PA) is much neglected,(1) and should be detected. A PA phenotype (low renin/high aldosterone) is best treated with aldosterone antagonists. Even more neglected is a Liddle phenotype (low renin/low aldosterone), for which the appropriate treatment is amiloride. Most guidelines do not even mention a Liddle phenotype, and mention amiloride only as an option for treatment of primary aldosteronism.(2)

However, a Liddle phenotype is far commoner than most physicians, even experts in Hypertension, suppose. In a study in Africa, in which appropriate therapy was identified by renin/aldosterone phenotyping, 19% of patients with resistant hypertension were switched to amiloride.(3) In the Jackson Heart Study, among 646 subjects with PRA results, 15.9% had a Liddle phenotype, and 9.3% had a PA phenotype.(4)

Yes, plasma renin and aldosterone should be measured, preferably in a stimulated condition,(5) in all patients with resistant hypertension 鈥� but not only for the purpose of identifying PA. A Liddle phenotype should receive the attention it warrants.

1. Brown JM, Siddiqui M, Calhoun DA, Carey RM, Hopkins PN, Williams GH, et al. The Unrecognized Prevalence of Primary Aldosteronism: A Cross-sectional Study. Ann Intern Med. 2020;173(1):10-20.
2. Spence JD. Blind spots in the new International Society of Hypertension guidelines: physiologically individualized therapy for resistant hypertension based on renin/aldosterone phenotyping, and amiloride for Liddle phenotype. J Hypertens. 2020;38(11):2338.
3. Akintunde A, Nondi J, Gogo K, Jones ESW, Rayner BL, Hackam DG, et al. Physiological Phenotyping for Personalized Therapy of Uncontrolled Hypertension in Africa. Am J Hypertens. 2017;30(9):923-30.
4. Huang X, Li J, Liu L, Chen G, Yi Y, Li P, et al. Interpreting stimulated plasma renin and aldosterone to select physiologically individualized therapy for resistant hypertension: importance of the class of stimulating drugs. Hypertens Res. 2019;42(12):1971-8.

1. Brown JM, Siddiqui M, Calhoun DA, Carey RM, Hopkins PN, Williams GH, et al. The Unrecognized Prevalence of Primary Aldosteronism: A Cross-sectional Study. Ann Intern Med. 2020;173(1):10-20.
2. Spence JD. Blind spots in the new International Society of Hypertension guidelines: physiologically individualized therapy for resistant hypertension based on renin/aldosterone phenotyping, and amiloride for Liddle phenotype. J Hypertens. 2020;38(11):2338.
3. Akintunde A, Nondi J, Gogo K, Jones ESW, Rayner BL, Hackam DG, et al. Physiological Phenotyping for Personalized Therapy of Uncontrolled Hypertension in Africa. Am J Hypertens. 2017;30(9):923-30.
4. Rayner BL, Spence JD. Physiological Treatment of Hypertension in Black Patients: Time for Action. Circulation. 2021;143(24):2367-9.
5. Huang X, Li J, Liu L, Chen G, Yi Y, Li P, et al. Interpreting stimulated plasma renin and aldosterone to select physiologically individualized therapy for resistant hypertension: importance of the class of stimulating drugs. Hypertens Res. 2019;42(12):1971-8.

CONFLICT OF INTEREST: None Reported

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