Real-World Clinical Experience of Rosuvastatin as a Lipid-Lowering Therapy for Primary and Secondary Prevention of Cardiovascular Events (REAL ROSE).

Background Rosuvastatin effectively reduces endogenous cholesterol synthesis and low-density lipoprotein (LDL) cholesterol and increases high-density lipoprotein (HDL) cholesterol. This study aimed to evaluate the clinical characteristics of patients and treatment patterns of rosuvastatin as a lipid-lowering therapy for primary and secondary prevention of cardiovascular events in Indian settings. Methods This real-world, retrospective multi-centric observational study included patients aged >18 years who received treatment with a rosuvastatin/rosuvastatin-based combination. Demographic and data about concomitant diseases and medications were recorded. Results Out of 1,816 patients, the majority were men (66.2%); the mean age was 54.1 years. The patients prescribed rosuvastatin for primary and secondary prevention of cardiovascular events were 71.9% and 28.1%, respectively. Rosuvastatin 10 mg (56.8%) was the most commonly prescribed dose. For primary prevention, 10 mg (65.0%) was the most preferred dose, and for secondary prevention, 20 mg (54.3%) was the most preferred dose. Rosuvastatin treatment significantly (pre- vs. post-treatment) reduced the levels of total cholesterol (227.2 vs. 178.4 mg/dL), triglycerides (212.6 vs. 154.4 mg/dL), and LDL cholesterol (167.0 vs. 125.6 mg/dL), and increased HDL cholesterol levels (40.7 vs. 44.3 mg/dL) (p<0.0001). A total of 1,196 patients received combination therapy with rosuvastatin (aspirin, 34.0%, and fenofibrate, 21.9%). Adverse events were reported in 0.4% of the study population (leg pain, nausea, muscle cramps/pain, bleeding, and myalgia). Conclusion This study demonstrated the clinical effectiveness and safety of moderate- to high-intensity rosuvastatin (5-40 mg) for primary and secondary prevention of cardiovascular events in the Indian population. A primary prevention strategy with statins can reduce cardiovascular events and associated morbidity and mortality.

WhatsApp-Based virtual consultation in clinical practice during COVID times: A prospective institutional study.

Background: As the novel coronavirus disease 2019 (COVID-19) continues its pandemic surge globally, the attention toward the treatment of non-COVID diseases has become difficult. Software-based systems and social media platforms could provide alternatives for ensuring regular health-care non-COVID diseases. In this context, we evaluated our own experience with virtual consultation (VC) for the management of endocrine surgical patients during the current COVID pandemic. Materials and Methods: This prospective study was conducted in the endocrine surgery department spanning 4 months from April to July 2020. We employed WhatsApp-based group video conferencing for VC with both new and follow-up outpatients. We evaluated the satisfaction quotient of patients, regarding the three types of consultations (no consultation, VC, and direct consultation) on an ordinal scale of three modes of consultation. Results: Virtual consultation was performed with 102 new and 285 follow-up patients. Goiters, clinical findings, and wounds/scars (in post-operative cases) were evaluated virtually. Dosage of thyroxine replacement, calcium supplementation, and other medications was prescribed based on findings and history. Patients who needed surgery (25/102 cases) were given appropriate appointment. More than 82% of the patients in both groups preferred VC during this COVID pandemic. Conclusions: More than 82% of both new and follow-up patients preferred VC over direct or no consultation during this COVID pandemic. Our findings suggest that VC through social media platforms is capable of ensuring appropriate treatment and follow-up for endocrine diseases.

RésuméContexte: Alors que la nouvelle maladie à coronavirus 2019 (COVID-19) poursuit sa poussée pandémique à l'échelle mondiale, l'attention portée au traitement des maladies non-COVID est devenue difficile. Les systèmes logiciels et les plates-formes de médias sociaux pourraient fournir des alternatives pour garantir soins de santé courants maladies non COVID. Dans ce contexte, nous avons évalué notre propre expérience de consultation virtuelle (VC) pour la gestion des patients en chirurgie endocrinienne pendant la pandémie actuelle de COVID. Matériels et méthodes: Cette étude prospective a été menée dans le service de chirurgie endocrinienne s'étendant sur 4 mois d'avril à juillet 2020. Nous avons utilisé la visioconférence de groupe basée sur WhatsApp pour VC avec les nouveaux patients et les patients de suivi. Nous avons évalué le quotient de satisfaction des patients, concernant les trois types de consultations (pas consultation, CV et consultation directe) sur une échelle ordinale de trois modes de consultation. Résultats: Une consultation virtuelle a été effectuée avec 102 nouveaux patients et 285 patients suivis. Les goitres, les signes cliniques et les plaies/cicatrices (dans les cas postopératoires) ont été évalués virtuellement. Le dosage du remplacement de la thyroxine, de la supplémentation en calcium et d'autres médicaments a été prescrit en fonction des résultats et des antécédents. Les patients qui chirurgie nécessaire (25/102 cas) ont reçu un rendez-vous approprié. Plus de 82 % des patients des deux groupes ont préféré la CV au cours de cette Pandémie de covid. Conclusions: plus de 82 % des nouveaux patients et des patients de suivi ont préféré la CV à la consultation directe ou à l'absence de consultation pendant cette période. Pandémie de covid. Nos résultats suggèrent que la CV via les plateformes de médias sociaux est capable d'assurer un traitement et un suivi appropriés pour les maladies endocriniennes. Mots-clés: COVID, endocrinien, suivi, chirurgie, thyroïde.

Management of Glucocorticoid-Induced Hyperglycemia.

Glucocorticoids are potent immunosuppressive and anti-inflammatory drugs used for various systemic and localized conditions. The use of glucocorticoids needs to be weighed against their adverse effect of aggravating hyperglycemia in persons with diabetes mellitus, unmask undiagnosed diabetes mellitus, or precipitate glucocorticoid-induced diabetes mellitus appearance. Hyperglycemia is associated with poor clinical outcomes, including infection, disability after hospital discharge, prolonged hospital stay, and death. Furthermore, clear guidelines for managing glucocorticoid-induced hyperglycemia are lacking. Therefore, this consensus document aims to develop guidance on the management of glucocorticoid-induced hyperglycemia. Twenty expert endocrinologists, in a virtual meeting, discussed the evidence and practical experience of real-life management of glucocorticoid-induced hyperglycemia. The expert group concluded that we should be proactive in terms of diagnosis, management, and post-steroid care. Since every patient has different severity of underlying disease, clinical stratification would help understand patient profiles and determine the treatment course. Patients at home with pre-existing diabetes who are already on oral or injectable therapy can continue the same as long as they are clinically stable and eating adequately. However, depending on the degree of hyperglycemia, modification of doses may be required. Initiating basal bolus with correction regimen is recommended for patients in non-intensive care unit settings. For patients in intensive care unit, variable rate intravenous insulin infusion could be temporarily used, but under supervision of diabetes inpatient team, and patients can be transitioned to subcutaneous insulin once stable baseline assessment and continual evaluation are crucial for day-to-day decisions concerning insulin doses. Glycemic variability should be carefully monitored, and interventions to treat patients should also aim at achieving and maintaining euglycemia. Rational use of glucose-lowering drugs is recommended and treatment regimen should ensure maximum safety for both patient and provider. Glucovigilance is required as the steroids taper during transition, and insulin dosage should be reduced subsequently. Increased clinical and economic burden resulting from corticosteroid-related adverse events highlights the need for effective management. Therefore, these recommendations would help successfully manage GC-induced hyperglycemia and judiciously allocate resources.

Selfie-driven thyroid disease leads: A study on a unique sign and its utility in clinical practice.

Introduction: Taking a photograph of self alone or with a group called selfie, has become modern-day rage with spurt in smartphone technology. It has catapulted from a hobby into psychiatric ailment, especially among teens and young adults. Although it is considered a psychiatric ailment keeping them aloof from social interactions, we observed an inadvertent advantage in this process. In this context, we present some intriguing findings in this study. Materials and Methods: This retrospective study was based on compilation of 14 cases from endocrine surgery outpatient cum inpatient database collected over 2 years' period. The inclusion criteria are the chief complaint (CC) was noted only after watching the selfie picture and not otherwise; the CC leads them to consult physician; the picture was captured by oneself or other person who was also part of that image; and the CC leads to definitive diagnosis of thyroid disease requiring treatment. All other clinical, investigative, and treatment (medical and surgical) were studied. Results: In all, we had 14/5820 (0.0024%) cases meeting the above criteria. CC and later confirmed in pictures were four cases of Grave's disease associated ophthalmopathic exophthalmos, eight cases of goiter, and two cases of facial puffiness (myxedema related). All these CC helped in investigating for the diagnosis of Graves' disease (4), nodular goiter (8), and hypothyroidism (2) confirmed by appropriate investigations. Ten cases underwent thyroidectomy (two of the nodular goiter cases were papillary thyroid cancer) and four cases took conservative medical treatment. Conclusions: Although selfie is considered a modern-day lifestyle-induced psychiatric illness, it can inadvertently help in picking up thyroid diseases in earlier stages.

RésuméIntroduction: Prendre une photo de soi seul ou avec un groupe appelé selfie, est devenu une rage moderne avec une poussée dans le smartphone La technologie. Il est passé d'un passe-temps à une maladie psychiatrique, en particulier chez les adolescents et les jeunes adultes. Bien qu'il soit considéré comme un maladie psychiatrique les gardant à l'écart des interactions sociales, nous avons observé un avantage par inadvertance dans ce processus. Dans ce contexte, nous présentent des découvertes intéressantes dans cette étude. Matériels et méthodes: Cette étude rétrospective a été basée sur la compilation de 14 cas de Base de données de chirurgie endocrinienne ambulatoire et hospitalière collectée sur une période de 2 ans. Les critères d'inclusion sont la plainte principale (CC) a été noté seulement après avoir regardé la photo selfie et pas autrement; le CC les amène à consulter un médecin ; l'image a été capturée par soi-même ou une autre personne qui faisait également partie de cette image ; et le CC conduit au diagnostic définitif d'une maladie thyroïdienne nécessitant un traitement. Tous les autres clinique, d'investigation et de traitement (médical et chirurgical) ont été étudiés. Résultats : Au total, nous avons eu 14/5820 (0,0024%) cas répondant aux critères ci-dessus Critères. CC et confirmés plus tard en images étaient quatre cas d'exophtalmie ophtalmopathique associée à la maladie de Grave, huit cas de goitre, et deux cas de gonflement du visage (liés au myxoedème). Tous ces CC ont aidé à enquêter pour le diagnostic de la maladie de Graves (4), nodulaire goitre (8) et hypothyroïdie (2) confirmées par des examens appropriés. Dix cas ont subi une thyroïdectomie (deux des cas de goitre nodulaire étaient un cancer papillaire de la thyroïde) et quatre cas ont suivi un traitement médical conservateur. Conclusions : Bien que le selfie soit considéré comme un maladie psychiatrique induite par le mode de vie, il peut aider par inadvertance à contracter des maladies thyroïdiennes à un stade précoce. Mots-clés: endocrinien, exophtalmie, goitre, selfie, thyroide, thyroidectomie.

Quantifying Remission Probability in Type 2 Diabetes Mellitus.

Type 2 diabetes mellitus (T2DM) is a chronic progressive disorder and is associated with significant morbidity and mortality. The concept of T2DM remission and the reversal of diabetic parameters to normal levels has been gaining momentum over the past years. T2DM remission is increasingly being recognized by various global guidelines. Multiple models have been developed and validated for quantifying the extent of remission achieved. Based on favorable clinical evidence, T2DM remission can be considered as the therapeutic goal in diabetes management and, in select cases, as an alternative to expensive treatment options, which can be burdensome as T2DM progresses. This narrative review discusses the available strategies, such as lifestyle interventions, physical activity, bariatric surgery, medical nutrition therapy, and non-insulin glucose-lowering medications, for achieving T2DM remission. Although the concept of T2DM remission has emerged as a real-world option, effective implementation in routine clinical practice may not be feasible until long-term studies prove the efficacy of different approaches in this regard.

Obesity a communicable disease - A new age paradigm.

Obesity has reached pandemic proportions globally and is now also affecting developing countries in the south Asian region. Though conventionally described as a non-communicable disease, in certain ways it can be transmitted from one individual to another. In this paper we describe the different ways in which obesity has been considered as a communicable disease. The role of gut microbiota in causing obesity, transfer of microbes causing changes in body composition, viral infections associated with human obesity and above all it being a socially contagious disease in view of rapid globalization, are few of the communicable attributes of obesity. This framework has also led to development of novel treatment strategies for managing this rapidly increasing pandemic.

Testosterone replacement therapy in men with type 2 diabetes mellitus and functional hypogonadism -an Integrated Diabetes and Endocrine Academy (IDEA) consensus guideline.

BACKGROUND: Though testosterone replacement therapy in men with organic hypogonadism is established, its role in men with type 2 diabetes mellitus (T2DM) and functional hypogonadism is unclear. METHODS: Thirteen experts addressed ten topic-specific questions after an in-depth review of literature, where all relevant issues were critically evaluated. RESULTS: Ten recommendations concerning diagnosis and management of men with T2DM and functional hypogonadism have been put forward. CONCLUSION: Routine measurement of serum testosterone in all, and inappropriate replacement of testosterone in asymptomatic T2DM men with functional hypogonadism and borderline low serum testosterone values, is not recommended.

Barophenotypic Characterization - The key to Person Centric Management of Obesity.

Obesity is now recognized as a chronic disease by many international medical societies. However, its comprehensive assessment is still a challenge in most clinical settings. This paper describes a novel practical approach to assess the barophenotype of a given individual. The word barophenotype is a portmanteau of "baro," which means weight, and phenotype, which reflects an external expression of a trait. This can be easily assessed using an ABCDE framework, encompassing the Adipose topography, Barophenotypic Behavior, Comorbidity assessment, Dysfunctionality, and Expectations. Furthermore, the utility of this framework in determining an appropriate person-centric therapeutic plan has also been described.

Glimepiride and Metformin Combinations in Diabetes Comorbidities and Complications: Real-World Evidence.

Objective To evaluate the usage of various strengths of glimepiride and metformin fixed-dose combinations in the management of type 2 diabetes mellitus (T2DM) patients with comorbidities and complications. Methods A retrospective, non-randomized, non-comparative, multi-centric real-world study included T2DM patients (age > 18 years) taking glimepiride and metformin fixed-dose combinations. Age, duration of diabetes, diabetes complications, comorbidities (hypertension and dyslipidemia), dosage frequency, and concomitant medications were analyzed from medical charts. Results A total of 4858 T2DM patients were included, with a mean age of 52.67 years and males being predominant in the study population (60.85%). The laboratory investigations showed a mean glycated hemoglobin (HbA1c) of 7.5, low-density lipoprotein (LDL) cholesterol of 104.81 ± 38.19 mg/dL, and serum creatinine of 0.88 ± 0.26 mg/dL. Around 2055 (42.30%) T2DM patients were hypertensive, and telmisartan alone and a telmisartan-based combination were the drugs of choice for hypertension management. Similarly, 1073 (22.08%) T2DM patients were having dyslipidemia and were primarily managed with rosuvastatin and its combination in 664 (62%) patients. Macrovascular complications were observed in 339 (6.97%) T2DM patients, among which coronary artery disease (CAD) had maximum prevalence, affecting 273 (5.61%) T2DM patients. Microvascular complications were 1010 (20.79%) T2DM patients, among which neuropathy had affected a maximum of 686 (14.12%) followed by retinopathy (2.34%) and nephropathy (1.81%). Among the available 11 strengths, the glimepiride 2 mg and metformin 500 mg combination were most widely prescribed in 1297 (26.69%), followed by glimepiride 1 mg and metformin 500 mg in 1193 (24.57%) patients, and the preferred dosage pattern was twice a daily in 2665 (54.85%) T2DM patients. An age-wise prescription analysis showed that glimepiride and metformin combinations were the preferred choice for the management of diabetes across all the age groups. Conclusion The real-world evidence in the Indian clinical setting indicates that glimepiride and metformin fixed-dose combinations are widely used in the management in T2DM patients with comorbidities like hypertension, dyslipidemia, and diabetes complications. Glimepiride and metformin fixed-dose combinations are suitable for early as well as long-standing diabetes.

Gla-100 Development: a Story of 'Serendipitous' Disruptive Innovation.

Ever since the discovery of insulin a century ago, relentless attempts have been made to develop insulins that closely mimic the timeaction- profile of human physiologic insulin. The early basal insulins like neutral protamine Hagedorn (NPH), were intermediate-acting, with high risk of hypoglycemia. These primary limitations led to attempts at developing improved basal insulins with a longer duration of action. After several attempts at prolonging insulin action using phenol and structural modifications of the insulin hexamer, insulin glargine was developed in 1988. The superior and unique pharmacological properties, longer duration of action, and significantly lowered risk of hypoglycemia enabled insulin glargine to be distinguished from NPH as a better basal insulin, providing holistic glycemic control. The present review highlights the circumstances that led to the search of truly basal insulins, focusing on the journey of insulin glargine 100 U/mL (Gla-100).

Persistent Elevation of Parathormone Levels after Surgery for Primary Hyperparathyroidism.

BACKGROUND: Persistent elevation of serum parathyroid hormone (PTH) despite normocalcemia have been documented in 8- 40% of patients after parathyroidectomy. We hereby report our experience from different centers across India to determine clinical significance of postoperatively elevated PTH levels and review relevant literature. METHODS: We conducted a retrospective case series study and reviewed all the patients who underwent surgery for primary hyperparathyroidism (PHPT) from April 2010 to January 2020. RESULTS: Total of 201 patients was diagnosed as PHPT. Out of available follow-up data of 180 patients, a total of 54 patients (30%) had persistently elevated PTH (PePTH) at 1 month. Patients with PePTH were older with higher preoperative serum calcium, iPTH, alkaline phosphatase and lower serum phosphate and 25-hydroxy vitamin D3 levels. Creatinine clearance was found to be significantly lower in patients with PePTH. Multiple linear regression analysis revealed that preoperative 25-OH D3 concentration, creatinine clearance and iPTH are the factors influencing persistent elevation of PTH levels. Significantly lower serum calcium and higher alkaline phosphatase levels were observed in PePTH patients with preoperative 25-OH D3 levels <20 ng/mL. Thirty patients at 6 months, 24 patients at 1 year, 18 patients at 2 years and 9 patients at 3 years had eucalcemic PTH elevation. Nine out of 126 (7%) patients with normal initial postoperative calcium and iPTH levels developed PePTH, with none culminating into recurrent hyperparathyroidism. CONCLUSION: Though the pathogenesis of such a phenomenon still remains to be elucidated, a multifactorial mechanism appears to play a role.

The SECURE model: A comprehensive approach for obesity management.

With rapidly increasing prevalence of obesity worldwide, it has become imperative to generate a comprehensive and easy to use clinical model for its management. We propose a simplified yet systematic approach to an obese patient, for a personalised patient centric obesity management. The SECURE model encompasses three domains in evaluation of the patient (Severity assessment, Etiological evaluation and Comorbidity workup) and the other three pillars for obesity treatment (Urge life style changes, Role of medications and surgery and Expected goal setting). This provides a clinical action checklist that may be useful even in other chronic non communicable disorders.

Person-centred Obesity Care - Techniques, Thresholds, Tools and Targets.

Obesity is a complex syndrome with multifactorial etiopathogenesis, multifaceted clinical presentations, multidimensional therapeutic approaches, and multipronged treatment strategies. These create the need for a person-centred approach to the management of obesity. This opinion piece explores the spectrum of person-centred obesity care. The authors describe the person-centred nature of techniques used to detect obesity, the thresholds used to diagnose it, the tools (treatment strategies) used to manage it, and the therapeutic outcomes aimed for. The discussion highlights the vast spectrum of obesity and its impact on health, and underscores the need for healthcare professionals to take a person-centred approach to its evaluation and management.

The Bhubaneswar Declaration on Sports Endocrinology, 2018.

Sports and endocrinology are complex interrelated disciplines. Sports and exercise modulate endocrine and metabolic health, and are used to prevent and manage disease. Endocrine and metabolic function influence participation and performance in sports activity. The Bhubaneswar Declaration, released on the occasion of the Endocrine Society of India Conference, resolves to promote the science of sports endocrinology. The authors commit to optimize endocrine health in sports persons, encourage safe use of sports to promote health, and prevent misuse of endocrine interventions in sports.

Bariatric surgery and diabetes remission: Who would have thought it?

Type 2 diabetes mellitus (T2DM) and obesity are increasingly common and major global health problems. The Edmonton obesity staging system clearly pointed towards increased mortality proportionate to the severity of obesity. Obesity itself triggers insulin resistance and thereby poses the risk of T2DM. Both obesity and T2DM have been associated with higher morbidity and mortality and this calls for institution of effective therapies to deal with the rising trend of complications arising out of this dual menace. Although lifestyle changes form the cornerstone of therapy for both the ailments, sustained results from this modalities is far from satisfactory. While Look AHEAD (action for HEAalth in diabetes) study showed significant weight loss, reduction in glycated hemoglobin and higher remission rate of T2DM at 1(st) year following intensive lifestyle measures; recurrence and relapse rate bounced back in half of subjects at 4 years, thereby indicating that weight loss and glycemic control is difficult to maintain in the long term with lifestyle interventions. Same recurrence phenomenon was also observed with pharmacotherapy with rimonabant, sibutramine and orlistat. Bariatric surgery has been seen to associate with substantial and sustained weight loss in morbidly obese patients. Interestingly, bariatric surgeries also induce higher rates of short and long-term diabetes remission. Although the exact mechanism behinds this diabetes remission are not well understood; improved insulin action, beta-cell function and complex interplay of hormones in the entero-insular axis appears to play a major role. This article reviews the effectiveness of bariatric procedures on remission or improvement in diabetes and put a perspective on its implicated mechanisms.

Bariatric surgery and diabetes remission: how far have we progressed?

Obesity and type 2 diabetes mellitus have been associated with higher morbidity and mortality. Bariatric surgery results in substantial and sustained weight loss in morbidly obese patients and improves obstructive sleep apnea. Furthermore, bariatric surgery improves diabetes control, hypertension, quality of life, stroke, myocardial infarction and reduces mortality. Interestingly, bariatric surgery induces high rates of short and long-term diabetes remission. While the exact mechanisms behind this are not completely understood, improved insulin action, ß-cell function and a complex interplay of hormones in the entero-insular axis appear to play major roles. Insulin action improves proportionally to weight loss and it gets completely normalized especially after bilio-pancreatic diversion. ß-Cell function also seems to improve after a variety of bariatric surgeries. Seemingly, baseline ß-cell function is able to predict future diabetes remission. This article will review the effectiveness of bariatric procedures on the remission and improvement of diabetes and its implicated mechanisms.

Prediction of remission after metabolic surgery using a novel scoring system in type 2 diabetes - a retrospective cohort study.

BACKGROUND: Remission of diabetes is seen in more than 60% of patients after bariatric surgery. There is extensive variability in the remission rates between different surgical procedures. We analyzed our database and aimed to develop an easy scoring system to predict the probability of diabetes remission after two surgical procedures i.e. Ileal Interposition coupled with Sleeve Gastrectomy (IISG) or Diverted Sleeve Gastrectomy (IIDSG). METHODS: In this retrospective study, we analyzed records pertaining to patients who underwent IISG (n = 46) and IIDSG (n = 29). The primary outcome measure was diabetes remission (A1c <6.5% and not requiring hypoglycemic drugs). We identified seven preoperative clinical variables (age, duration of diabetes, body mass index, micro and macrovascular complications, use of insulin and stimulated C-peptide) based on our previous reports to be included in the diabetes remission score (DRS). The DRS score (7 - 14) was compared between the patients with and without remission in both the surgery groups. RESULTS: Mean DRS in patients who underwent IISG was 9.2 ± 1.4. Twenty one (46%) had a remission in diabetes. DRS was significantly lower in patients with remission than patients without remission (8.1 ± 0.8 versus 10.2 ± 0.9, p < 0.0001). Mean DRS in patients who underwent IIDSG was 10.4 ± 1.3. Twenty one (72%) had a remission in diabetes. DRS was significantly lower in patients with remission than patients without remission (9.7 ± 0.8 versus 12.0 ± 0.5, p < 0.0001). Patients with a DRS ≥ 10 in IISG group and more than 12 in IIDSG group did not get into remission. CONCLUSION: Preoperative DRS can be a useful tool to select the type of surgical procedure and to predict the postoperative diabetes remission. TRIAL REGISTRATION: NCT00834626.

A case of Liddle's syndrome; unusual presentation with hypertensive encephalopathy.

Liddle's syndrome is a rare cause of secondary hypertension. Identification of this disorder is important because treatment differs from other forms of hypertension. We report an interesting case of a 35-year-old lady, a known diabetic and hypertensive patient, who presented with features of hypertensive encephalopathy. The family history was unremarkable. Past treatment with various combinations of antihypertensive medications including spironolactone, all at high doses, failed to control her blood pressure. Upon evaluation, the patient had hypokalemic alkalosis, low 24-h urine potassium and suppressed plasma renin activity. Although these findings were similar to hyperaldosteronism, plasma aldosterone was lower than the normal range. Blood pressure decreased markedly after administration of amiloride. Along with hyporeninemic hypo-aldosteronism, the non-responsiveness to spironolactone and good response to amiloride established the diagnosis of Liddle's syndrome.