Antihypertensive Drugs Interfering With Aldosterone–Renin Ratio Measurement
For aldosterone–renin ratio (ARR) screening for primary aldosteronism, interfering antihypertensive drugs should be withdrawn when safe, because several drug classes alter renin and/or aldosterone and can produce false-positive or false-negative ARR results. [1]
Core Drug Classes Recommended for Withdrawal
The Endocrine Society guideline provides medication-management strategies that require withdrawing the following interfering agents before ARR testing (with specific timelines). [1]
- Mineralocorticoid receptor antagonists (MRAs) (including spironolactone and eplerenone) should be withdrawn. [1]
- Epithelial sodium-channel (ENaC) inhibitors (including amiloride and triamterene) should be withdrawn. [1]
- Other diuretics should be withdrawn. [1]
- β-blockers should be withdrawn. [1]
- Centrally acting α2-agonists (including clonidine and α-methyldopa) should be withdrawn. [1]
- ACE inhibitors should be withdrawn. [1]
- ARBs should be withdrawn. [1]
- Dihydropyridine calcium channel blockers (including amlodipine) should be withdrawn. [1]
- SGLT2 inhibitors should be withdrawn. [1]
Selection Algorithm for Medication Withdrawal Strategy
Two Endocrine Society strategies are described for screening while medication effects are being managed. [1]
- Minimal medication withdrawal is implemented by stopping MRAs and ENaC inhibitors for 4 weeks before testing. [1]
- Ideal full medication withdrawal is implemented by stopping MRAs, ENaC inhibitors, and other diuretics for 4 weeks before testing and stopping β-blockers, ACE inhibitors, ARBs, dihydropyridine calcium channel blockers, centrally acting α2-agonists, and SGLT2 inhibitors for 2 weeks before testing. [1]
Common ARR Interference Patterns
- β-blockers and centrally acting α2-agonists are associated with a possible false-positive ARR when ARR is screened without withdrawing these agents. [1]
- Withdrawal of MRAs/ENaC inhibitors/diuretics is intended to reduce false-negative screening caused by medication effects on aldosterone and renin. [1]
Practical Timing for Withdrawal When Safe
- 4 weeks before testing: MRAs, ENaC inhibitors, and other diuretics. [1]
- 2 weeks before testing: β-blockers, ACE inhibitors, ARBs, dihydropyridine CCBs, centrally acting α2-agonists, SGLT2 inhibitors. [1]
Additional Antihypertensive Agents Listed as Interfering in the Guideline Tables
In the Endocrine Society medication-management tables, additional agents are listed among medications to withdraw in certain management strategies. [1]
- Hydralazine should be considered for withdrawal. [1]
- α-blockers should be considered for withdrawal. [1]
- Non-dihydropyridine calcium channel blockers should be considered for withdrawal. [1]
- Moxonidine should be considered for withdrawal. [1]