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21-01-2025 | Hyperaldosteronism | News

Experts create treatment response criteria in primary aldosteronism

Author: Laura Cowen

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medwireNews: An international panel of experts has developed consensus criteria for defining a complete, partial, or absent biochemical or clinical response to targeted medical treatment of primary aldosteronism.

“The Primary Aldosteronism Medical Treatment Outcome (PAMO) criteria represent an […] outcome standard that can guide clinical practice and research into primary aldosteronism,” write Jun Yang (Hudson Institute of Medical Research, Clayton, Victoria, Australia) and co-authors in The Lancet Diabetes & Endocrinology.

The three response categories (complete, partial, or absent) within the PAMO criteria are based on the biochemical outcomes of correction of hypokalemia and normalization of plasma renin activity or renin concentration, while the clinical outcomes focus on improvements in blood pressure. The authors also provide guidance on clinical contexts where the PAMO criteria may not apply, such as in patients with a high sodium diet and those with poor medication compliance, among others.

When Yang and team applied the criteria to 1258 patients (mean age 52 years, 51.5% men) with primary aldosteronism who started targeted medical treatment between 2016 and 2021, they found that, in the absence of a previous treatment-target paradigm, 52.9% of 1057 participants with biochemical data at follow-up achieved a complete biochemical response, defined as normal serum potassium (>3.6 mmol/L) and plasma renin activity (>1 ng/mL per h) or renin concentration (>10 mU/L).

Furthermore, just 18.3% of 1248 patients with clinical data at follow-up achieved complete clinical response, defined as an office blood pressure below 140/90 mmHg, home blood pressure below 135/85 mmHg, and 24 h blood pressure below 130/80 mmHg, without additional antihypertensive treatment.

Yang et al say that these findings “raise important questions about the adequacy of primary aldosteronism treatment around the world and highlight the need for strategies to increase rates of complete biochemical and clinical treatment response, including early disease detection and intensification of targeted treatment.”

After adjustment for potential confounders, the researchers identified several characteristics that were significantly associated with the odds of having a complete biochemical response. These included baseline potassium concentration (odds ratio [OR]=1.78 with each mmol/L increase), a complete clinical response (OR=1.58 versus not having a complete clinical response), baseline plasma renin activity (OR=1.19 with each ng/mL per h increase), aldosterone concentration (OR=0.95 with each 100 pmol/L increase), the use of β-adrenergic blockers (OR=0.62 versus no use), and a lateralization index above 4 at adrenal venous sampling with or without adrenocorticotropic hormone stimulation (OR=0.56 versus below 4).

The median daily dose of spironolactone was significantly higher among patients with a complete biochemical response than among those with an absent response (40 vs 25 mg) but only in unadjusted analyses.

The study also revealed that a complete clinical response was significantly more likely in women (OR=2.10), and in people with higher baseline serum potassium concentrations (OR=1.48 per mmol/L) and normal adrenal morphology on imaging (OR=1.46). By contrast, it was significantly less likely in those with characteristics such as lower systolic blood pressure (OR=0.98 per mmHg), and end organ damage including microalbuminuria and/or left ventricular hypertrophy (R=0.58).

Yang and co-authors conclude: “The PAMO criteria can be used to guide medication titration in routine clinical practice but are not intended as strict goalposts for individual patients whose treatment should be tailored to their clinical context.”

They add: “Further studies will be needed to evaluate the association between different PAMO categories and longer-term patient outcomes, as well as the impact of applying PAMO criteria on these outcomes.”

medwireNews is an independent medical news service provided by Springer Healthcare Ltd. © 2025 Springer Healthcare Ltd, part of the Springer Nature Group

Lancet Diabetes Endocrinol 2025; doi:10.1016/S2213-8587(24)00308-5

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