This year’s ENDO conference in San Francisco highlighted numerous advances across basic science, emerging therapies, and strategies for improving quality of care. A key theme emphasized throughout the conference was the importance of collaborating across specialties to ensure patients are appropriately screened and treated. Notably, the new Endocrine Society guideline on the management of primary aldosteronism has significant implications for primary care, cardiology, nephrology, and other specialties. Osteoporosis, another common condition, was also addressed in a dedicated session reviewing recent guidelines and best practices.
- Primary Aldosteronism—New Diagnosis and Treatment Guideline
Primary aldosteronism (PA) is the most common endocrine cause of hypertension and is likely underdiagnosed due to historically low screening rates. Compared to other causes of hypertension, PA carries a significantly higher risk of heart attack, stroke, atrial fibrillation, heart failure, and chronic kidney disease. Fortunately, it is a highly treatable condition, with effective options including medications such as spironolactone or surgical intervention. While clinical trials demonstrating cardiovascular mortality benefits usually garner significant attention, this has not been the case with PA — likely due to limited clinician awareness and the complexity of prior diagnostic algorithms. The updated guidelines now recognize the clear opportunity to improve screening and treatment rates, to reduce cardiovascular morbidity and mortality.
The new guidelines suggest screening for primary aldosteronism in all individuals with hypertension. This represents a significant departure from the previous dogma that individuals with PA will have severe hypertension on multiple medications. To screen for PA, clinicians should order serum aldosterone, plasma renin (either plasma renin activity or direct renin concentration), and potassium levels. It’s essential to note that severe hypokalemia can lead to false-negative results, so potassium levels should be corrected if they are significantly low before testing. In contrast to prior practice, the updated guideline recommends that antihypertensive medications can be continued during testing, with additional guidance to help interpret results and repeat testing when they do not align with clinical expectations.
A diagnosis of primary aldosteronism is likely when the following criteria are met:
- a suppressed renin (plasma renin activity PRA <1 ng/ml/h or direct renin concentration DRC <8.2 mU/L)
- inappropriately elevated aldosterone > 10 ng/dL, and
- aldosterone to renin ratio of >20 (using PRA) or >70 (using DRC).
Another notable change is the reduced emphasis on confirmatory testing — now termed aldosterone suppression testing — which is generally reserved for specific cases to guide surgical planning. Instead of delaying treatment to pursue complex diagnostic procedures, the guidelines encourage establishing the diagnosis based on initial bloodwork and proceeding directly to treatment discussions.
First-line medical treatment for primary aldosteronism is spironolactone, a commonly used mineralocorticoid receptor antagonist that addresses the underlying hormonal cause of hypertension in PA. Treatment goals include reducing blood pressure, correcting hypokalemia, and, when possible, minimizing the number of antihypertensive medications required. As cases of PA detection increase, patients with primary aldosteronism can continue to be referred to an endocrinologist, but initiation of medical therapy does not necessarily need to be delayed until they can see a specialist.
In summary, the new Endocrine Society guideline suggests screening all patients with hypertension for primary aldosteronism and simplifies the diagnostic process to expedite treatment with spironolactone or surgery.
- Osteoporosis—Diagnosis and Treatment Goals
Osteoporosis is another common medical condition, contributing to approximately 37 million fractures annually worldwide and generating significant healthcare costs. While no new guidelines were issued this year, a dedicated session titled “Paradigm Shifts in Osteoporosis” addressed persistent gaps between guideline recommendations and clinical practice, and highlighted strategies for improving implementation.
Osteoporosis is diagnosed either by a low T-score on a DXA scan or after a low-trauma fracture involving the spine, hip, or wrist. Unfortunately, the diagnosis is often missed — even when vertebral fractures are incidentally noted on imaging. Timely diagnosis is critical, as patients are at the highest risk for repeat fractures during the two years immediately following the initial fracture. This post-fracture period represents a key opportunity for diagnosis and intervention, complementing routine DXA-based screening.
Regarding treatment selection, current guidelines recommend stratifying patients based on fracture risk. Patients classified as very high risk — those with a recent low-trauma fracture or a DXA T-score ≤-2.5 combined with a prior fracture — should ideally receive an osteoanabolic agent as first-line therapy. Options include romosozumab, teriparatide, and abaloparatide. These agents are most effective when used as initial treatment, and their efficacy is reduced if started after bisphosphonate (e.g., alendronate, zoledronic acid) or denosumab therapy. Nevertheless, initiating any treatment reduces the risk of fracture, and treatment decisions should be individualized based on patient preference, clinical judgment, and resource availability. Treatment effectiveness can be monitored objectively through bone density improvement, with a 3% increase in total hip bone density over three years serving as a measurable target.
Recognizing fractures—particularly vertebral, hip, or wrist fractures — as clinical indicators of osteoporosis is essential to initiating therapy during the high-risk period following the initial fracture. While anabolic agents are preferred for those at highest risk of recurrent fractures, any pharmacologic intervention proven to reduce fracture risk is preferable to no treatment.
Dr. Hansen has no conflicts of interest to report.
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