ODP054 The Impact of SGLT2-inhibitors on Renin-Aldosterone axis and Adrenal Incidentaloma's work up: Case study and literature review

INTRODUCTION: SGLT2 inhibitors (SGLT2i) are being increasingly used in patients with Type 2 DM given their glycemic effects along with cardio-protective and reno-protective effects. SGLT2i exert these effects through various mechanisms, mainly through the RAAS (Renin-Angiotensin-Aldosterone System) with diuresis, leading to transient elevation of renin levels with minimal effect on aldosterone levels. We present a case where elevated aldosterone levels improved stoppage of SGLT2i. Case 52 year male with history of GERD and Sleep apnea who was referred for evaluation of right adrenal incidentaloma of 2 cm found on CT abdomen in 12/2019 as part of renal stone work up. Initial work up in 3/2020 showed elevated aldosterone of 87.1, renin of 2.3 with ratio of 37.9. Repeat work up in 7/2020 showed elevated aldosterone of 66 with renin levels of 2. High urine aldosterone of 64.7 was noted but urine sodium of 171 mg only. Urine metanephrine and normetanephrine levels were in the reference range. He was started on spironolactone considering hyperaldosteronism and mild hypertension, but developed hyperglycemia and type 2 diabetes mellitus which was initially treated with insulin and later switched to Jardiance. Follow up CT abdomen with adrenal protocol in 8/2020 showed stable right adrenal nodule, consistent with adrenal adenoma. His repeat aldosterone levels remained elevated at 70 with renin levels of 2.8 in 6/2021 after holding spironolactone for 2 weeks. Patient was advised to stop Jardiance as well as continue holding Spironolactone in 9/2021 and repeated labs showed an improvement in aldosterone levels of 43 in 10/2021 and 21 in 12/2021 with renin levels of 2.79 and 2.95 respectively. DISCUSSION: SGLT2 inhibitors are known to reduce heart failure hospitalization in the clinical trials. Use of SGLT2i leads to early diuresis with natriuresis and systemic RAAS activation rather than intra-renal RAAS activation. Effects are mainly mediated through transient natriuresis with volume depletion in short term, leading to RAAS activation with transient renin elevation but no significant effects on aldosterone levels, possibly due to other controlling factors like ACTH and K levels along with circadian rhythm. Our case presents unique scenario where elevated aldosterone with normal (non-suppressed) renin levels were noted in the context of adrenal incidentaloma work up and Jardiance use. Even though the improvement of aldosterone levels might be related to multiple factors but with increasing use of SGLT2i, much attention should be paid to the impact of these agents on renin-aldosterone axis and possible need of holding these agents if elevated renin-aldosterone levels are noted. Presentation: No date and time listed