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dromlakhani (@dromlakhani) published this skill. Their other Agent Skills are listed on their SkillMD profile.

Endo Avoid Aldosterone Suppression Test by dromlakhani

Name: Endo Avoid Aldosterone Suppression Test
Rating: 4.666666666666667 (3 reviews)
Author: dromlakhani

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.

dromlakhani Updated Sep 8, 2026 10 repo stars

File contents

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

---name: endo-avoid-aldosterone-suppression-testdescription: 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.---# 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 ExampleA 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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