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Daily Medical Update
Adrenal hormonal excess
Saturday, July 04, 2026
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🔬 Practice-Changing Findings
Evidence from RCTs and meta-analyses published in the
last 12 months.
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The Journal of Clinical Endocrinology and Metabolism (2025) - Clinical Practice Guideline
Key Findings
- The guideline expands screening to all patients with hypertension in order to improve detection of primary aldosteronism using aldosterone, renin, and the aldosterone-to-renin ratio.
- Primary aldosteronism-specific medical or surgical treatment is recommended to improve blood pressure control and reduce aldosterone-related cardiovascular events, with MRA up-titration advised when renin remains suppressed.
📋 Practice Implication: Lower the threshold to test hypertensive patients for primary aldosteronism and use renin response to judge whether medical therapy is adequately blocking aldosterone excess.
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European Journal of Endocrinology (2025) - Pooled Phase 2/3 Trial Analysis
Key Findings
- Most patients reduced urinary free cortisol to the normal range within 4 to 12 weeks, with a median time to first control of 35 days.
- Adverse events were more frequent during dose titration than during long-term treatment, and 16.2% of patients discontinued treatment because of adverse events.
📋 Practice Implication: Set expectations that osilodrostat often works within weeks, but concentrate safety monitoring and dose adjustment during the initial titration period.
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Hypertension (2025) - Meta-analysis
Key Findings
- Adrenalectomy produced a greater reduction in indexed left ventricular mass than mineralocorticoid receptor antagonist therapy, with a mean difference of -3.5%.
- Left ventricular hypertrophy risk fell by 32% after adrenalectomy versus 19% with mineralocorticoid receptor antagonists, and left ventricular ejection fraction improved modestly after surgery.
📋 Practice Implication: When unilateral primary aldosteronism is confirmed and the patient is operable, adrenalectomy offers a stronger chance to reverse aldosterone-mediated cardiac remodeling.
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The Lancet Diabetes & Endocrinology (2025) - Systematic Review and Meta-analysis
Key Findings
- Patients with unsuppressed renin after mineralocorticoid receptor antagonist treatment had lower cardiovascular event risk than those with persistent renin suppression, with a pooled hazard ratio of 0.43.
- The cardiovascular risk reduction was stronger after at least 5 years of follow-up, with a pooled hazard ratio of 0.33, while renal outcomes were not significantly improved by renin status.
📋 Practice Implication: Treat renin normalization as a practical treatment target during long-term mineralocorticoid receptor antagonist therapy, especially when trying to lower cardiovascular risk.
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Diabetes Care (2025) - Randomized Double-Blind Placebo-Controlled Trial
Key Findings
- At 24 weeks, mifepristone lowered HbA1c versus placebo by a least-squares mean difference of -1.32 percentage points in patients with type 2 diabetes and hypercortisolism.
- Common adverse events included hypokalemia, fatigue, nausea, vomiting, headache, peripheral edema, diarrhea, and dizziness, and blood pressure increases were also reported.
📋 Practice Implication: In patients with difficult-to-control diabetes and biochemical hypercortisolism, cortisol receptor blockade can improve glycemia but requires active monitoring for potassium and blood pressure toxicity.
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Summary
Recent evidence in adrenal hormonal excess is dominated by primary aldosteronism, where updated guidance supports broader hypertension screening and new meta-analyses link subtype-directed treatment and renin-guided mineralocorticoid receptor antagonist titration to better cardiovascular outcomes. For hypercortisolism, pooled LINC data show rapid sustained biochemical control with osilodrostat in Cushing's disease, and a randomized trial found mifepristone improved glycemic control in patients with inadequately controlled type 2 diabetes plus hypercortisolism.
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