Research

Work up a patient with confirmed hypercalcemia using the PTH-dependent vs. PTH-independent algorithm — order the right second-tier tests (PTHrP, 25(OH)D, 1,25(OH)2D, SPEP/UPEP, urinary calcium/creatinine clearance ratio, TSH) to reach a diagnosis. Trigger when a clinician asks "what's causing this hypercalcemia", "how to work up high calcium", "what tests to order for hypercalcemia", "PTH is normal what next", "differential diagnosis of hypercalcemia", or shares a confirmed hypercalcemia and ...

Recommends initiating intravenous isotonic saline hydration as initial management for hypercalcemia of malignancy (HCM) while awaiting antiresorptive therapy, with fluid rate adjusted according to cardiac function. Triggered when a clinician encounters a patient with HCM (e.g., serum calcium >12 mg/dL, symptoms of hypercalcemia) and seeks immediate measures before specific drugs are available.

Computes albumin‑adjusted (corrected) serum calcium using total calcium and albumin to adjust for hypo‑ or hyperalbuminemia. Triggered when a clinician notes hypoalbuminemia and requests corrected calcium to assess true hypercalcemia of malignancy severity.

Provides a checklist of five evidence-based measures to enhance the technical success of adrenal venous sampling procedures. Triggers include when preparing for AVS and asking 'How can I maximize success rate?' or troubleshooting failed attempts.

Determines when adrenal venous sampling (AVS) is indicated for functional subtyping of primary aldosteronism (PA) when surgical treatment is feasible and desired by the patient. Triggered when a clinician confirms PA diagnosis and asks 'Do I need AVS for subtyping?' or evaluates surgical candidacy.

Evaluates likelihood of primary aldosteronism by measuring plasma aldosterone suppression after oral captopril; normal suppression ≥30% makes PA unlikely, while lack of suppression with persistently suppressed plasma renin activity suggests PA. Use when assessing captopril challenge test (CCT) results for PA diagnosis in patients with positive aldosterone-to-renin ratio.

Determines unilateral vs bilateral aldosterone excess based on cortisol-corrected aldosterone ratios from adrenal venous sampling, with ratio >4:1 indicating unilateral excess, ratio 3:1 suggestive of bilateral hypersecretion, and interpretation dependent on cosyntropin stimulation protocol used during sampling. Use when analyzing AVS results to guide surgical vs medical treatment decisions; triggers include 'AVS lateralization ratio', 'cosyntropin-stimulated AVS', 'aldosterone-to-cortisol ra...

Calculates the lowest effective glucocorticoid dose (dexamethasone or prednisone) to normalize blood pressure and serum potassium in glucocorticoid-remediable aldosteronism (GRA/FH-I) by titrating to biochemical and clinical targets. Indicated when initiating medical treatment for confirmed GRA, triggered by findings such as early-onset hypertension, family history of stroke before age 40, spontaneous hypokalemia, or suppressed plasma renin activity with elevated aldosterone.

Determines whether adrenal venous sampling (AVS) is needed in addition to CT for lateralizing primary aldosteronism before surgery. Trigger phrases include "patient with primary aldosteronism considering surgery", "unilateral adrenal adenoma on CT", "surgical candidate", and "age <35 with hypokalemia and >1‑cm adenoma".

Determines when to avoid aldosterone suppression testing in hypertensive patients with a positive PA screen who have normokalemia and suppressed aldosterone below assay‑specific cutoffs (<11 ng/dL immunoassay or <8 ng/dL LC‑MS/MS), indicating low likelihood of primary aldosteronism. Use when a clinician asks whether to skip confirmatory suppression testing based on low pretest probability.

Recommends diagnostic testing to exclude primary adrenal insufficiency (PAI) in acutely ill patients presenting with otherwise unexplained volume depletion, hypotension, hyponatremia, hyperkalemia, fever, abdominal pain, hyperpigmentation, or hypoglycemia (especially in children). Use when clinical suspicion arises from these suggestive signs or symptoms suggestive of PAI.

Recommends fludrocortisone 100 µg daily for children with primary adrenal insufficiency and confirmed aldosterone deficiency; for infants under 12 months, adds sodium chloride supplementation. Triggered by PAI with aldosterone deficiency, evidenced by salt craving, hyponatremia, hyperkalemia, or elevated renin with low aldosterone.

Suggests that pregnant patients with primary adrenal insufficiency be monitored for clinical signs of glucocorticoid over- or under-replacement such as normal weight or gain, fatigue, postural hypotension or hypertension, and hyperglycemia, with at least one review each trimester. Use when managing a pregnant patient with PAI to assess glucocorticoid dosing adequacy.

This skill outlines monitoring of mineralocorticoid replacement in primary adrenal insufficiency, focusing on clinical assessment of salt craving, postural hypotension, or edema alongside serum electrolyte measurements. It is initiated when evaluating patients on fludrocortisone therapy to ensure adequate dosing and avoid over- or under-replacement.

Monitors glucocorticoid replacement in primary adrenal insufficiency (PAI) patients using clinical assessment of body weight, postural blood pressure, energy levels, and signs of frank glucocorticoid excess. Trigger phrases include "PAI patient on glucocorticoid replacement," "assess for weight gain or insomnia," and "evaluate for postural hypotension or fatigue."

Recommends initiating fludrocortisone 50–100 µg daily for mineralocorticoid replacement in adults with confirmed aldosterone deficiency (e.g., low aldosterone, elevated renin) and no salt restriction. Use when aldosterone deficiency is confirmed in a patient with primary adrenal insufficiency (PAI) presenting with salt craving or postural hypotension.

Recommends immediate IV hydrocortisone stress dosing for patients with suspected adrenal crisis presenting with severe adrenal insufficiency symptoms such as hypotension, hyponatremia, hyperkalemia, or acute abdominal pain. Use when clinician observes signs of adrenal crisis (e.g., syncope, delirium, marked abdominal tenderness) prior to diagnostic test results.

Suggests a trial of dehydroepiandrosterone (DHEA) replacement in women with primary adrenal insufficiency (PAI) who report low libido, depressive symptoms, and/or low energy levels despite otherwise optimized glucocorticoid and mineralocorticoid replacement. Consider when a woman with PAI presents with persistent low libido, depressive symptoms, and/or low energy levels after glucocorticoid and mineralocorticoid doses have been titrated to clinical targets.

Initiates a 6‑month trial of DHEA replacement in women with primary adrenal insufficiency (PAI) who have persistent low libido, depressive symptoms, or low energy despite otherwise optimized glucocorticoid and mineralocorticoid therapy. If the patient does not report a sustained beneficial effect after 6 months, discontinue DHEA.

Recommends confirmatory testing with corticotropin stimulation test in patients presenting with clinical symptoms or signs suggesting PAI (e.g., fatigue, hypotension, hyponatremia, hyperpigmentation) when the patient's condition permits safe testing. Use when a clinician identifies suggestive features and circumstances allow outpatient stimulation testing without imminent need for emergency glucocorticoids.

This skill guides annual evaluation of patients with primary adrenal insufficiency (PAI) for symptoms and signs of glucocorticoid and mineralocorticoid over- or under-replacement. Use during annual follow-up when assessing for weight changes, blood pressure abnormalities, edema, or symptoms such as fatigue, insomnia, or salt craving.

This skill suggests using prednisolone as an alternative glucocorticoid when hydrocortisone is unavailable for emergency treatment of adrenal crisis. Dexamethasone is the least-preferred option and should only be administered if no other glucocorticoid is available.

Suggests adjusting glucocorticoid dose according to severity of illness or magnitude of the stressor in patients with primary adrenal insufficiency. Use when patient with PAI has intercurrent illness, fever, or stress.

The Endocrine Society guideline recommends against routine hormonal monitoring of glucocorticoid replacement in primary adrenal insufficiency and advises adjusting therapy solely based on clinical response. Use when evaluating glucocorticoid dose adequacy, such as when patients report fatigue, weight loss, hypotension, or signs of Cushingoid over-replacement.