How do I install the Esa Pa Gra Add Mra skill?

Run npx skillmds@latest add dromlakhani/esa-pa-gra-add-mra in your terminal (requires Node.js), paste this page's agent-chat prompt into Claude, Cursor, or any MCP-connected agent, or download the SKILL.md file and copy it into your agent's skills directory.

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Is Esa Pa Gra Add Mra free to use?

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Who published Esa Pa Gra Add Mra?

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

Esa Pa Gra Add Mra by dromlakhani — Agent Skill

Name: Esa Pa Gra Add Mra
Rating: 4.2 (5 reviews)
Author: dromlakhani

Esa Pa Gra Add Mra

Determines whether to add a mineralocorticoid receptor antagonist (e.g., spironolactone or eplerenone) to glucocorticoid therapy in glucocorticoid-remediable aldosteronism when blood pressure fails to normalize with glucocorticoid alone. Triggered by persistent hypertension or inadequate BP control despite optimized glucocorticoid dosing in GRA patients.

dromlakhani Updated Aug 19, 2026 10 repo stars

File contents

Determine When to Add MR Antagonist in GRA Treatment

STEP 1 — Gather Information

Confirm GRA diagnosis via genetic testing (CYP11B1/CYP11B2 chimeric gene) or strong clinical/family history; document current glucocorticoid type, dose, and timing; measure seated BP and serum potassium; assess for hypokalemia or symptoms of mineralocorticoid excess.

STEP 2 — Rule In / Rule Out

Has BP normalized (systolic <140 mmHg and diastolic <90 mmHg, or age‑ and gender‑specific target) on current glucocorticoid monotherapy? If yes, continue glucocorticoid alone; if no, proceed to consider MR antagonist addition.

STEP 3 — Classify or Stratify

Classify response as glucocorticoid‑responsive (BP at target) or glucocorticoid‑nonresponsive (BP above target). For nonresponsive cases, evaluate need for MR antagonist while ensuring glucocorticoid dose is already minimized per age/weight.

STEP 4 — Decide

Add an MR antagonist: start spironolactone 12.5–25 mg once daily or eplerenone 25 mg twice daily; titrate to BP goal while checking serum potassium and creatinine every 1–2 weeks; maintain lowest effective glucocorticoid dose.

Clinical Guardrails / Mimics / Pitfalls

Monitor for hyperkalemia, especially in renal impairment or when potassium supplements are used; avoid MR antagonists in pregnancy; do not escalate glucocorticoid dose beyond physiologic replacement to prevent iatrogenic Cushing; ensure glucocorticoid is minimized before adding MR antagonist to avoid overtreatment.

Concrete Clinical Example

A 10‑year‑old with genetically confirmed GRA on prednisone 2.5 mg daily had BP 148/92 mmHg after 6 weeks; spironolactone 12.5 mg daily was added, BP improved to 122/78 mmHg and potassium remained 4.6 mmol/L after 4 weeks.

Source: The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, DOI:10.1210/jc.2015-4061

---name: esa-pa-gra-add-mradescription: Determines whether to add a mineralocorticoid receptor antagonist (e.g., spironolactone or eplerenone) to glucocorticoid therapy in glucocorticoid-remediable aldosteronism when blood pressure fails to normalize with glucocorticoid alone. Triggered by persistent hypertension or inadequate BP control despite optimized glucocorticoid dosing in GRA patients.---# Determine When to Add MR Antagonist in GRA Treatment## STEP 1 — Gather InformationConfirm GRA diagnosis via genetic testing (CYP11B1/CYP11B2 chimeric gene) or strong clinical/family history; document current glucocorticoid type, dose, and timing; measure seated BP and serum potassium; assess for hypokalemia or symptoms of mineralocorticoid excess.## STEP 2 — Rule In / Rule OutHas BP normalized (systolic <140 mmHg and diastolic <90 mmHg, or age‑ and gender‑specific target) on current glucocorticoid monotherapy? If yes, continue glucocorticoid alone; if no, proceed to consider MR antagonist addition.## STEP 3 — Classify or StratifyClassify response as glucocorticoid‑responsive (BP at target) or glucocorticoid‑nonresponsive (BP above target). For nonresponsive cases, evaluate need for MR antagonist while ensuring glucocorticoid dose is already minimized per age/weight.## STEP 4 — DecideAdd an MR antagonist: start spironolactone 12.5–25 mg once daily or eplerenone 25 mg twice daily; titrate to BP goal while checking serum potassium and creatinine every 1–2 weeks; maintain lowest effective glucocorticoid dose.## Clinical Guardrails / Mimics / PitfallsMonitor for hyperkalemia, especially in renal impairment or when potassium supplements are used; avoid MR antagonists in pregnancy; do not escalate glucocorticoid dose beyond physiologic replacement to prevent iatrogenic Cushing; ensure glucocorticoid is minimized before adding MR antagonist to avoid overtreatment.## Concrete Clinical ExampleA 10‑year‑old with genetically confirmed GRA on prednisone 2.5 mg daily had BP 148/92 mmHg after 6 weeks; spironolactone 12.5 mg daily was added, BP improved to 122/78 mmHg and potassium remained 4.6 mmol/L after 4 weeks.**Source:** The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, DOI:10.1210/jc.2015-4061

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