LAS VEGAS — Nearly half of the people with resistant hypertension have a secondary adrenal cause, with endogenous hypercortisolism at least as common as primary hyperaldosteronism, results from the MOMENTUM study showed.

Moreover, a recent analysis of data from the observational study also revealed that a small percentage of people with resistant hypertension have both hyperaldosteronism and hypercortisolism.

“The occurrence of both these adrenal conditions is not rare, and concomitant screening for both should be considered in patients with resistant hypertension,” who make up about 13% of all individuals with hypertension, said Lance A. Sloan, MD, president of the Texas Institute for Kidney and Endocrine Disorders in Lufkin, Texas, during his presentation at the American Association of Clinical Endocrinology (AACE) Annual Meeting 2026.

While awareness about primary hyperaldosteronism as a secondary cause of resistant hypertension has been increasing over the years, the same has not happened with endogenous hypercortisolism, Sloan, who is also a clinical assistant professor at The University of Texas Medical Branch in Galveston, and Sam Houston State University, Conroe, both in Texas, told Medscape Medical News.

“Everybody’s been told for decades now that hyperaldosteronism is common, and we’re under diagnosing and undertreating it. But nobody is hearing that hypercortisolism is also common in resistant hypertension,” he said.

“People know it’s a cause, but they think it’s rare. Part of the reason for that is the old way of diagnosing was to look at the patient and decide if they look like they have Cushing’s syndrome, and if they don’t look like they have it, don’t work it up,” Sloan explained. “We now know that while severe hypercortisolism is uncommon, mild is not so uncommon and is treatable. So we need to consider hypercortisolism when people with hypertension or diabetes don’t respond to medicines the way we expect them to.”

Prevalence of Hypercortisolism in Resistant Hypertension

The 50-center, observational MOMENTUM trial examined the prevalence of hypercortisolism in 1086 adults with resistant hypertension, defined as systolic blood pressure (BP) ≥ 130 mm Hg despite taking three or more antihypertensives from different classes including a diuretic or four or more antihypertensives from different classes regardless of systolic BP.

Researchers used the 1 mg dexamethasone suppression test (DST) to screen for endogenous hypercortisolism, which is convenient and the most sensitive test for the adrenal condition, Sloan noted.

Hypercortisolism was defined as a post-DST cortisol level > 1.8 µg/dL and dexamethasone level ≥ 140 ng/dL in patients with common causes of false positive DSTs excluded.

The main finding, presented earlier this year at the American College of Cardiology 2026 Scientific Session, was a hypercortisolism prevalence of 27.3% in the study population. The mean post-DST cortisol for these patients was 4.2 µg, and their mean dexamethasone level was 484.2 ng/dL. Adrenal nodules were reported in 24.3% of those with post-DST cortisol level of ≥ 1.8 µg/dL.

Individuals with hypercortisolism didn’t look different than those without, but they did have lower BMI and waist circumference values. There were no differences in BP medications.

Those with hypercortisolism also tended to take more glucose-lowering medications, with significant differences found for SGLT2 inhibitors (25% vs 18%; P < .05), fast-acting insulin (13% vs 8%; P < .01), basal insulin (20% vs 12%; P < .001). On the other hand, those without hypercortisolism were more likely to be taking tirzepatide (9% vs 5%; P < .05).

The new analysis showed that hyperaldosteronism, defined by plasma renin activity of < 1.0 ng/mL/h, aldosterone level of > 10 mg/mL, and aldosterone to renin ratio of > 20 ng/dL, was present in 18% of all participants with resistant hypertension, which is consistent with the literature. In addition, a total of 4% with hypercortisolism also had hyperaldosteronism.

The prevalence of primary hyperaldosteronism was similar in those with (14%) and without (19%) hypercortisolism.

Last year, the Endocrine Society recommended in its primary hyperaldosteronism treatment guidelines that everyone with hypertension — not just resistant hypertension — be tested for hyperaldosteronism, noted Sloan.

In any case, “if you’re going to screen everybody for hyperaldosteronism, you should be screening everybody for hypercortisolism too, at least in the resistant hypertension population,” he added.

Lifting Some of the Burden of Hypertension

Asked to comment, session moderator Catherine Anastasopoulou, MD, PhD, associate professor of medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, agreed with Sloan’s interpretation and conclusions.

“The truth is that hypercortisolemia is as common, if not more common, than hyperaldosteronism,” she said.

And “if you find a secondary cause, you can really lift some of the burden of the hypertension. Patients can have much better control, even if it is not completely cured. They can have less burden of medications, always a very good goal to set for quality of life,” she told Medscape Medical News.

Anastasopoulou also said that while resistant hypertension management falls under cardiology and nephrology as well as endocrinology, primary care clinicians need to be aware as well. “Patients don’t need to wait to see a specialist to be checked. The percentage that make it to subspecialists is probably much less than the population that could benefit from testing.”

Sloan told Medscape Medical News that he buys dexamethasone for patients rather than sending them to the pharmacy for it. “In fact, it would cost me more money and time to write the prescription than just to buy the medicine and give it to them. We go out and buy a big bottle, put the pills in little plastic bags, and tell patients exactly how to take it between 11:00 and 12 o’clock at night, and to be at the lab by 8:00 AM the next morning.”

He said that while the pill and the cortisol test are fairly inexpensive, the dexamethasone level “might be a little more, but in general, compared to many things we order and do, it is pretty inexpensive.”

The primary MOMENTUM results are being submitted for publication in a peer-reviewed journal. “The exact timing of release is not known at present but hopefully soon,” a Corcept Therapeutics representative told Medscape Medical News.

The study was funded by Corcept Therapeutics. Sloan reported serving as a clinical investigator, consultant, and/or speaker for Abbott, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Corcept Therapeutics, Eli Lilly, GlaxoSmithKline, Janssen, Merck, Novo Nordisk, Pfizer, and Sanofi Aventis. Anastasopoulou reported having no disclosures.

Miriam E. Tucker is a freelance journalist based in the Washington, DC, area. She is a regular contributor to Medscape, with other work appearing in the Washington Post, NPR’s Shots blog, and diaTribe. She is on X @MiriamETucker and BlueSky @miriametucker.bsky.social.