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endo.primary_aldosteronism.v1PRODUCTION
endo.primary_aldosteronism.v1

Primary aldosteronism (Conn syndrome)

endocrinologychronicsubacuteadult
Hard-required inputs
0 / 9
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm PA (autonomous aldosterone with suppressed renin); rule out secondary aldosteronism (ADA 2026)

Inputs
1
Actions
0
Advance rule
Set
Advance when

Biochemical confirmation

Patient inputs (12)

Anatomical assessment after biochemical confirmation (ADA 2026)

Younger patients more likely to benefit from surgery (ADA 2026)

Severity and response monitoring (ADA 2026)

Severity (ADA 2026)

Wash out / substitute interfering drugs before ARR (especially MRA) (ADA 2026)

Drug interference with ARR (ADA 2026)

Hypokalemia (often present); replete before ARR (ADA 2026)

Screening test (>20 with aldosterone >15 ng/dL suspicious) (ADA 2026)

Renin interpretation; saline suppression cautious (ADA 2026)

Confirmatory saline suppression (>10 ng/dL after 2L NS positive) (ADA 2026)

Alternative confirmatory (>12 µg/day with sodium repletion) (ADA 2026)

Lateralization for surgical candidate (gold standard for subtype) (ADA 2026)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningsevere_hypokalemia_with_arrhythmia
    K+ <2.5 with weakness / paresthesia / ECG changes (ADA 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmalignant_htn_with_end_organ_damage
    BP ≥180/120 with end-organ damage in PA (ADA 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereunilateral_disease_on_AVS
    Lateralization on AVS (lateralization index >4 with cosyntropin) (ADA 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepa_with_adrenal_mass_gt_4cm
    Adrenal mass >4 cm on CT in patient with PA (ADA 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepositive_arr_for_confirmatory
    ARR ≥20 with aldosterone ≥15 ng/dL (ADA 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatespironolactone_gynecomastia
    Painful gynecomastia or breast tenderness on spironolactone (ADA 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatefamilial_pa_under_20
    PA <20 yr or family history of stroke <40 (ADA 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

INITIAL_WORKUPrequiredDrives dose adjustment
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Recommended regimen

Medical management of PA (ADA 2026)
axis: pa_medical
Selected axis "Medical management of PA (ADA 2026)" by default fallback (first axis)
  • spironolactone
    first line
    MRA_non_selective
    12.5–25 mg • PO • daily, titrate to 100–200 mg
    triggers: PA_medical_or_bilateral
    First-line MRA; gynecomastia common (ADA 2026)
    rxcui 9997
  • eplerenone
    second line
    MRA_selective
    25 mg BID • PO • BID, titrate to 100 mg/day
    triggers: spironolactone_intolerant, gynecomastia
    Selective MRA; fewer endocrine SE; renal dose adjust (ADA 2026)
    rxcui 298869
  • amiloride
    second line
    epithelial_Na_blocker
    5–10 mg • PO • daily
    triggers: MRA_intolerant
    Distal Na+ channel blocker; K-sparing (ADA 2026)
    rxcui 644
  • triamterene
    second line
    epithelial_Na_blocker
    50–100 mg • PO • BID
    triggers: amiloride_alternative
    Alternative K-sparing (ADA 2026)
    rxcui 10763
  • chlorthalidone
    add on
    thiazide_like_diuretic
    12.5–25 mg • PO • daily
    triggers: BP_above_target_on_MRA
    Combination for BP control (ADA 2026)
    rxcui 2409
  • amlodipine
    add on
    DHP_CCB
    5–10 mg • PO • daily
    triggers: BP_above_target_on_MRA
    2025 AHA HTN combination
    rxcui 17767
  • lisinopril
    add on
    ACEi
    10 mg • PO • daily
    triggers: BP_above_target_on_MRA
    2025 AHA HTN
    rxcui 29046

outpatient playbook — drug actions (2)

  1. 1. spironolactone
    12.5–25 mg → 100–200 mg • PO • daily
    trigger: PA confirmed, medical management (ADA 2026)
    First-line (ADA 2026)
  2. 2. eplerenone
    25 mg BID → 100 mg/day • PO • BID
    trigger: Spironolactone SE (ADA 2026)
    Selective (ADA 2026)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Resistant HTN (≥3 antihypertensives incl diuretic) at goal not achieved (ADA 2026); Spontaneous hypokalemia or thiazide-induced disproportionate hypokalemia (ADA 2026); HTN onset <30 yr (ADA 2026).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Primary aldosteronism (Conn syndrome)** (endo.primary_aldosteronism.v1).
Phenotype framing: APA vs bilateral adrenal hyperplasia vs unilateral hyperplasia vs glucocorticoid-remediable vs adrenal carcinoma (ADA 2026)
Scope: Confirm PA (autonomous aldosterone with suppressed renin); rule out secondary aldosteronism (ADA 2026)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Medical management of PA (ADA 2026)**.
1. spironolactone 12.5–25 mg PO daily, titrate to 100–200 mg (MRA_non_selective, first line) — First-line MRA; gynecomastia common (ADA 2026)
2. eplerenone 25 mg BID PO BID, titrate to 100 mg/day (MRA_selective, second line) — Selective MRA; fewer endocrine SE; renal dose adjust (ADA 2026)
3. amiloride 5–10 mg PO daily (epithelial_Na_blocker, second line) — Distal Na+ channel blocker; K-sparing (ADA 2026)
4. triamterene 50–100 mg PO BID (epithelial_Na_blocker, second line) — Alternative K-sparing (ADA 2026)
5. chlorthalidone 12.5–25 mg PO daily (thiazide_like_diuretic, add on) — Combination for BP control (ADA 2026)
6. amlodipine 5–10 mg PO daily (DHP_CCB, add on) — 2025 AHA HTN combination
7. lisinopril 10 mg PO daily (ACEi, add on) — 2025 AHA HTN

Setting playbook (outpatient) — Screen, confirm, subtype, manage medically or surgically (ADA 2026)
8. spironolactone 12.5–25 mg → 100–200 mg PO daily — PA confirmed, medical management (ADA 2026) (First-line (ADA 2026))
9. eplerenone 25 mg BID → 100 mg/day PO BID — Spironolactone SE (ADA 2026) (Selective (ADA 2026))

Non-pharmacologic actions:
- Adrenalectomy referral if unilateral (ADA 2026)
- Lifestyle (Na restriction, exercise) (ADA 2026)
- OSA screen + CPAP (ADA 2026)

AVOID / contraindication checks:
- MRA block if K gt 5 (ADA 2026)
- Eplerenone renal dose adjust (ADA 2026)
- ARB MRA combo monitor K (ADA 2026)

Monitoring

Regimen monitoring:
- BP home log (ADA 2026)
- BMP K q1w x4 then q3m (ADA 2026)
- breast tenderness screen on spironolactone (ADA 2026)

Setting (outpatient) monitoring:
- BP target <130/80 (ADA 2026)
- BMP q3m (ADA 2026)

Follow-up plan: Endo q3–6 mo; cardiology / nephrology as needed; PASO classification post-op (ADA 2026)
- Close-out criterion: Follow-up booked

Monitoring phase: BP home log, K+, creatinine, gynecomastia / breast tenderness on spironolactone, post-op ARR (ADA 2026)

Disposition

Current setting: outpatient — Screen, confirm, subtype, manage medically or surgically (ADA 2026)

Disposition criteria:
- Continue medical or post-op follow-up (ADA 2026)

Escalation triggers (move to higher acuity):
- Severe hypoK / malignant HTN → ED (ADA 2026)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] K+ <2.5 with weakness / paresthesia / ECG changes (ADA 2026)
- [LIFE_THREATENING] BP ≥180/120 with end-organ damage in PA (ADA 2026)
- [SEVERE] Lateralization on AVS (lateralization index >4 with cosyntropin) (ADA 2026)

Citations

- Endocrine Society 2016 PA Guideline (Funder); SPARTACUS (Lancet 2016); PASO 2017 [PMID:26934393](https://pubmed.ncbi.nlm.nih.gov/26934393/)
- Cited evidence (PMID 27325147) [PMID:27325147](https://pubmed.ncbi.nlm.nih.gov/27325147/)
- Cited evidence (PMID 28576687) [PMID:28576687](https://pubmed.ncbi.nlm.nih.gov/28576687/)

Last reconciled with current guidelines: 2026-05-22.
References