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No the issue is the patient following the recommended treatment which usually works and I can document by urine sodium/K. BELIEVE IT OR NOT SOME PATIENTS DO NOT TELL THE TRUTH OR HAVE NOT LEARNED WHERE THEIR EXCESS IS COMING FROM.In some cases we can measure the blood levels of drugs but not in most HTN. When this is done in studies we find out that 50% of the pts who say they are taking their meds properly are not.I do not want to recommend surgery if the recommended therapy has "failed" because the patient is not following the protocol. I want to continue working with the pt to see if we can figure out why. IF THIS CANNOT be done then I will begin to work on using more drugs and may work up to 6 different classes of drugs if pt can tolerate and feels well. If not then go to surgery if AVS lateralizes. If it does not and there is a bump on one side and pt not able to tolerate and agrees to risk of no improvement and will still need drugs then do unilat surgery.If still BP and low K prob that is not tolerable then take out other gland as well. This should be very rare these days.Esp if pt can DASH.CE Grim MD Dr. Grim, I get what you are saying but this is a great example of how the "bias" that originally sparked this discussion comes across. Below you state if "either has FAILED to DASH and take meds as directed." Right there, this sounds to me as if you are viewing the patient as noncompliant and putting the blame on them, rather than viewing them as human beings with lives to live, and taking into account that the "failure" may not be their fault. > > Well if the medical team has documented that either has failed to DASH > and take meds as directed then I would also recommend surgery. > > You seem to leave out one of the key messages here. If you DASH and > fail to get to DASH GOALS and despite repeated urine testing that > shows you cant do this then I would also recommend surgery after AVS. > If AVS does not lateralize and BP cannot be controlled on meds and > DASH then one can also do bilateral adrenalectomy which I have > recommended and seen successful results but then medical management > becomes a real task for both the pt and the team including more > careful dietary management to prevent sudden death from Addision's. > > I have been there and done that and rarely recommend this now. > > CE Grim MD >