Jes Pa Treatment Selection

---
name: jes-pa-treatment-selection
description: Determines whether to recommend adrenalectomy or mineralocorticoid receptor antagonists for primary aldosteronism based on PA subtype and patient/surgical factors. Triggered after subtype confirmation when clinicians ask “Should this patient have surgery or medical treatment?” or discuss treatment options with the patient.
---

# Select between adrenalectomy and medical therapy for PA management

## STEP 1 — Gather Information
Collect AVS results (or alternative subtype diagnosis) to determine unilateral vs bilateral PA, patient age, serum potassium, PAC, adrenal CT findings, patient preference for surgery, and surgical contraindications.  
**Action:** Proceed to subtype classification.

## STEP 2 — Rule In / Rule Out
Is PA unilateral? If yes, proceed to evaluate surgical suitability; if no (bilateral), recommend medical therapy with MRAs.  
**Action:** For bilateral PA, start MRA therapy; for unilateral PA, move to candidacy assessment.

## STEP 3 — Classify or Stratify
Among unilateral PA patients, assess surgical candidacy: age <35 years, spontaneous hypokalemia (<3.5 mEq/L), PAC >300 pg/mL, unilateral adrenal tumor on CT, patient desire for surgery, and absence of major surgical comorbidities.  
**Action:** Classify as surgical candidate if criteria met; otherwise classify as non‑surgical candidate.

## STEP 4 — Decide
If surgical candidate, recommend adrenalectomy; if non‑surgical candidate (unilateral PA not meeting criteria) or bilateral PA, recommend medical therapy with MRAs.  
**Action:** Initiate adrenalectomy or MRA therapy accordingly.

## Clinical Guardrails / Mimics / Pitfalls
Do not recommend adrenalectomy without confirming unilateral subtype; avoid bypassing AVS in patients >35 years or lacking typical features (hypokalemia, high PAC, unilateral tumor); respect patient refusal of surgery even when criteria are met; do not initiate MRAs in bilateral PA without subtype confirmation; monitor for postoperative hyperkalemia and adrenal insufficiency if cortisol co‑secretion is suspected; avoid MRAs in patients with severe renal impairment or hyperkalemia risk without appropriate precautions.

## Concrete Clinical Example
A 32‑year‑old woman with spontaneous hypokalemia (K⁺ 3.2 mEq/L), PAC 350 pg/mL, ARR 650, and a 1.8 cm left adrenal adenoma on CT undergoes AVS showing lateralization index > 4 with ACTH. She meets all surgical criteria and desires curative treatment. Laparoscopic left adrenalectomy is performed, normalizing BP and K⁺ postoperatively.

**Source:** Japan Endocrine Society clinical practice guideline for the diagnosis and management of primary aldosteronism 2021, Japan Endocrine Society, 2021