practical pearls for primary care. evaluation and treatment of hypertension
TRANSCRIPT
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Practical Pearls for Primary Care
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Evaluation and Treatment of Hypertension
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A 58 yo man is diagnosed with hypertension. His BP’s are 160/96, 160/100, and 158/96 on 3 outside readings. He has been on a low sodium diet and he is not obese.
PMH- hyperlipidemia, GERD and gout. What would be the most appropriate treatment?
A) Low salt diet and exercise
B) Hydrochlorathiazide
C) Doxazosin
D) ACE inhibitor
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When Thiazides Are Not A Good Choice
History of Gout Creatinine > 1.6 Lithium use
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Diuretic Choice
Strongly consider chlorthalidone Long acting, great data Major drawback has been hypokalemia
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Pearls in the Treatment of Hypertension
Remember when not to use hydrochloathiazide: renal insufficiency , gout
Chlorthalidone has longer half life, better efficacy than HCTZ
Spironolactone avoids hypokalemia, avoid in renal insufficiency, be careful if patient on an ACEI or ARB. Remember gynecomastia
Losartan can lower uric acid
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A 60 yo man presents for follow-up of hypertension. He has been taking medication (Lisinopril) for the past 3 months. His most recent outside blood pressure readings are 156/94, 150/96, 158/92. PMH: Type 2 DM, GERD, depression. Meds: Lisinopril 20mg qd, Rabeprazole 20mg qd, Sertraline 50 mg qd, Glyburide 10 mg qd.
What do you recommend? A) No changes in therapy B) Increase Lisinopril to 20 mg BID C) Add Hydrochlorathiazide 12.5 mg qd D) Add Amlodipine (Norvasc) 5mg qd E) Add Clonidine .1mg BID
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Combination Therapy
Low doses of thiazide can be very effective in combination with ACE inhibitors (12.5 mg of thiazide)
Thiazide ACE combination can be further enhanced by moderate dietary salt restriction
ACE/Amlodipine combination may have CV benefi slightly better than ACE/diuretic in high risk diabetic paients
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A 58 yo woman is seen for treatment of hypertension. She has not ever had good control of her hypertension since treatment was started 2 years ago. She has been taking her medications faithfully. Meds: Felodipine (Plendil), Atenolol , Clonidine, and Losartan (Cozaar). On exam her BP is 200/106 P-55.Labs- BUN 30, Cr 2.0, Na 137, K 4.0. ECG- LVH
What would you recommend?
A) Increase felodipine from 10mg a day to 10mg BID
B) Increase losartan from 50mg BID to 100mg BID
C) Add hydrochlorathiazide 12.5 mg qd
D) Add hydrochlorathiazide 25 mg qd
E) Add furosemide 40 mg BID
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Refractory Hypertension Occurs in 5% of hypertensive patients Always carefully evaluate for medication
adherence. Worse with increasing obesity Think of secondary causes Sleep apnea Ingestion of substances that interfere with
treatment (especially NSAIDS)
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Treatment of Refractory Hypertension
Most have too much volume. Furosemide extremely useful, especially if renal insufficiency present
Strongly consider using spironolactone Simplify regimens if possible to improve
adherence
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AHA Recommendations For Treatment of Hypertension
Indication BP goal Initial therapy B Blocker
Low risk <140/90 ACE/CCB/Thi NoHigh risk <130/80 ACE/CCB/Thi NoWith CAD <130/80 BB and ACE YesCHF < 120/80 BB/ACE/Aldo Yes Diuretics
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How Can You Tell What Kind Of Headache It Is?
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A 29 yo woman is evaluated for headaches. She reports having headaches about twice a month. She feels pain behind her right eye and frequently pain on her forehead. Her headaches often get better with 550 mg of Naprosyn. She has never had visual problems or nausea with her headaches. The headaches are worse with exercise. About once a month the headache is bad enough to force her to leave work early.
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What is the Most Likely Type of Headache?
A)Migraine
B)Cluster
C)Muscle tension
D)Nitrate headache
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Clinical Features of Tension Type Headache
Mild Headache Often described as tightness, vice like Neck to forehead can be involved Often helped by NSAIDS Worse during times of stress Not disabling
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Clinical Features of Migraine Headaches
Family history common Pulsating quality Worse with activity Mild to Severe in intensity Can be disabling History of motion sickness common Nausea, photophobia, phonophobia may
occur
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Diagnosing Migraine POUNDing Pneumonic Pulsating Duration 4-72 hOurs Unilateral Nausea DisablingIf 4 criteria met LR is 24 for migraineIf 3 met LR 3.5If 2 or fewer LR.41
JAMA 2006: 296: 1274-1283
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A 29 yo woman presents for evaluation. She reports that she has frequent headaches over the past 12 months that include pressure pain on her forehead, under her eyes and over her cheeks. She usually has nasal congestion as well. She has not had any fevers or purulent nasal discharge. What is the most likely problem?
A) Cluster headaches
B) Migraine headaches
C) Sinus headaches
D) Tension headaches
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“Sinus” Headaches Are Usually Migraine Headaches
2991 patients screened who reported at least 6 headaches during the previous 6 months self diagnosed or physician diagnosed as sinus headaches
88% of these patients met IHS criteria for migraine HA (80%) or migrainous criteria (8%).Most common sx patients reported were sinus pressure (84%), sinus pain (82%) and nasal congestion (63%)
Arch Intern Med 2004;164 (16): 1769-1772
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Sinus, Allergy and Migraine Study
100 patients recruited who believed they had sinus headaches. All received a detail history and PE and given headache diagnosis based on HIS criteria
Final diagnosis were as follows: Migraine with or without aura 52%, probable migraine 23%, chronic migraine with medication overuse HA 11%, nonclassifiable HA 9%. 76% of migraine patients reported pain in the distribution of the 2nd division of the trigeminal nerve and 62% experienced bilateral forehead and maxillary pain with their HA’s.
Headache 2007;47:213-224
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Treatment of Sinus Headache as Migraine: The Diagnostic Utility of
Triptans To determine the response rate to triptans in
alleviating “sinus headache” in patients with endoscopy and CT negative sinus exams
Prospective study of patients with physician or patient self diagnosed sinus headaches with negative workup all treated with triptans
54 patients enrolled, 38 completed follow up. 31 patients (82%) had significant reduction in headache pain with triptan use, 35 (92%) had a response to migraine directed therapy.
Laryngoscope 2008;Dec; 2235-2239.
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Tip Offs That a Headache is Not of Sinus Orgin
Absence of fever Absence of purulent drainage Chronicity
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Frequency of Headache Types
Tension Type – Most common
Migraine - Common
Cluster - Rare
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Treatment Pearls for Migraine
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Role of Metoclopramide
Good efficacy when combined with NSAID. Equivalent to sumatriptan oral if patient has nausea.
My boost effect of oral triptan or other oral migraine treatments
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Metoclopramide vs Hydromorphone
Retrospective cohort study to evaluate metoclopramide vs hydromorphone for initial ED treatment of migraine
200 patients, 51 received IV or IM hydromorphone, 95 received IV metoclopramide and 54 received a different medication.
Using a 1-10 pain scale, mean pain scale reductions were 2.3 for hydromorphone, 3.7 for metoclopramide and 2,8 for all other meds (p<.001).
Less rescue meds and faster ED discharge with metoclopramide
J Pain 2008;9 (1): 88-94.
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Sumatriptan + Naproxen Sustained pain free response 2-24 hours, the
combination is superior to either drug by itself (p<.01) . Dose used 85 mg sumatriptan/500mg naproxen (1)
In patients with poor prior response to triptans, the combination was significantly more effective than placebo (p<.001) (2)
1)JAMA 2007;297:1443-1454.
2) Headache 2009;49:971-982.
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Oral treatment protocol for moderate to severe HA
NSAID + motility drug (Metoclopramide)
no relief
Oral triptan
no relief
Oral narcotic
no relief
ER/office visit for IV therapy
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Infectious Disease Pearls
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A 55 yo man presents with discomfort in his leg and swelling. He has no chronic medical problems. He has had problems with athlete’s foot. Labs: WBC 12,000
VS : T- 37.5 BP 130/70 P 88
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What do you recommend?
A. Metronidazole
B. Ciprofloxacin
C. TMP/Sulfa
D. Vancomycin
E. Cefazolin
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The Role of A-Hemolytic Streptococci in Causing Diffuse, Nonculturable Cellulitis
- All patients admitted to one hospital with diffuse cellulitis over a 3 year period were enrolled. 179 were studied
- All patients had serologic studies for exposure to streptococci, response to antibiotics were recorded
- 131 positive for strep, 48 negative- 71/73 (97%) evaluable patients with positive strep
studies responded to B lactams, 21/23 (91%)with negative studies responded to B lactams (overall respones rate 95%)
Medicine 2010;89: 217-226
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Clinical Practice Guidelines for Treating MRSA
- For outpatients with nonpurulent cellulitis
(no purulent drainage or exudate, no abscess) empirical therapy for infection due to B hemolytic streptococci is recommended.
- Coverage for CA-MRSA is recommended in patients who do not respond to B lactam therapy.
Clin Inf Dis 2011; 52(3):e18-e55
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A 22 yo woman presents with dysuria, frequency and hematuria. No fever, chills or flank pain. Allergies:sulfa. Ua- 20-30 WBC’s/HPF
What do you recommend?
A. Urine culture
B. TMP/Sulfa
C. Ciprofloxacin
D. Nitrofurantoin
E. Cephalexin
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International Practice Guidelines for Uncomplicated Cystitis/Pyelonephritis in Women
Cystitis recommended antibiotics- Nitrofurantoin 100mg BID X 5 days- TMP/Sulfa DS BID X 3 days (if resistance
in the community <20% and not used in the past 3 months)
- Fosfomycin 3 gram single dose
Clin Inf Dis 2011; 52(5): e 103-120
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International Practice Guidelines for Uncomplicated Cystitis/Pyelonephritis in Women
Pyelonephritis- Always get a urine culture/sensitivities- Ciprofloxacin 500 mg BID (with IV initial dose if
appropriate) if community resistance to FQ <10%- If >10% FQ resistance, start with 1 gm ceftriaxone
dose or 24h dose of aminoglycoside- Further treatment based on urine sensitivities
Clin Inf Dis 2011; 52(5): e 103-120
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A 66 yo woman is seen for fevers and diarrhea. Had dental surgery 6 months ago and was given a 7 day course of amox/clav. Afterwards she developed fever and diarrhea and was dx with C diff. She has had 2 more recurrences since treated with vancomycin each time.Meds : Citalopram,omeprazole, zolpidem.
Her stool returns positive for C diff . What do you recommend?
A. Metronidazole X 2 weeksB. Vancomycin X 1 month (with taper)C. CholestyramineD. Fecal transplant
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Fecal Transplant for Recurrent C Difficile Infection
- 19 patients with recurrent CDI treated with fecal transplant delivered through colonoscope
- 18 patients had immediate response with resolution. One patient recovered after a 2nd transplant. Three had recurrences after receiving antibiotics.
J Clin Gastroenterology 2010;44: 567-570.
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A 36 yo woman presents with facial pain, congestion and low grade fevers for the past 7 days. On exam, T 37.9, P 80. Tenderness over left maxillary sinus.
What do you recommend?A) No antibiotic treatmentB) AmoxicillinC) Amoxicillin/ClavulanateD) AzithromycinE) Levofloxacin
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IDSA Guidelines for Treatment of Rhinosinusitis
Treat with antibiotics at 10 days of symptoms, treat earlier if A)T >39 AND purulent nasal discharge or severe facial pain B) “Double sickening”
Amoxicillin/Clavulanate the preferred antibiotic Do not use Azithromycin or TMP/Sulfa Quinolones or Doxycycline alternate choices for PCN
allergic patients
Clinical Infectious Diseases 2012;54(8):1041–5
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Using Common Drugs
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A 60 yo man returns for annual follow up. He has a history of hyperlipidemia and is being treated with atorvastatin 40 mg daily. His other medications include sertraline, omeprazole and vitamin D. What would you recommend?
A)Check fasting lipids
B)Check fasting lipids , CPK
C)Check fasting lipids, CPK, ALT,AST
D)Check fasting lipids, AST,ALT
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Is There Any Benefit to Checking Liver Enzymes in Statin Treated Patients?
408 patients undergoing statin treatment with at least one lab test (AST/ALT or CK) >10% above normal
36 (8.8%) were symptomatic when tests were drawn. Of 40 patients who had additional evaluation, only 2 had treatment changes (both symptomatic)
Expert Opinion Drug Saf 2011 (Nov 1)
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What is the Yield of Testing Transaminases?
Retrospective review of a primary care practice 1014 of 1194 patients on a statin had a
monitoring test done in a 1 year period 10 of 1014 patients (1%) had a significant
transaminase elevation, and 5 (0.5%) had a moderate transaminase elevation, but none were due to the statin
Arch Intern Med 2003;163():688-92
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A 60 yo man with Type 2 DM presents for evaluation. He has a strong family history of colon cancer . His other problems include CRI and hypertension. Most recent HBA1C was 7.4, He has been managing his diabetes with diet. Most recent Cr 1.8 (CrCl 49). What do you recommend for this patient?
A) Metformin B) Glypizide C) Glyburide D) Glargine
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Reduced Risk of Colorectal Cancer With Metformin in Patients With Type 2 DM
Meta-analysis of 4 studies, with 107,961 diabetic patients
Metformin treatment was associated with a significantly lower risk of colorectal cancer (RR .63, CI .47-.84, p=.002)
Diabetes Care 2011; 34: 2323-2328
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Metformin Package Insert
Lactic acidosis risk of 0.03 cases/ 1000, with a fatality rate of 0.015/1000
Discontinuation if Cr >1.5 in men and >1.4 in women, and advises against initiation in people > 80 years of age unless they have a normal creatinine clearance
Other contraindications include congestive heart failure requiring medical management, acute or chronic metabolic acidosis, and acute presentations of dehydration, hypotension, and sepsis
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Cochrane Review
206 studies 47,800 person-year of exposure to metformin,
and 38,200 patient-years in the non-metformin comparison group
no cases of fatal or non-fatal lactic acidosis in either group
96% of studies allowed for at least one high risk group to be included
Cochrane Database Syst. Rev.; 2005 Jul 20;(3)
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Incidence of Lactic Acidosis in Metformin Users (1)
Patients with a metformin prescription from 1980-1995 in Saskatchewan Health administrative database.
11,797 patients with 22,296 person years of exposure. Two patients had a hospital diagnosis for lactic acidosis (rate 9 /100,000)
Rate of lactic acidosis in diabetic patients not on metformin 9.7/100,000 (2).
1. Diabetes Care 1999 Jun: 22(6) 925-7 2. Diabetes Care 1998; 21:1659-1663
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Rational Recommendations for Metformin Use
eGFR Action >60 No contraindications
<60 and > 45 Continue use, check Cr every 3-6 months<45 and >30 Use lower dose (1/2 dose) Check Cr every 3 months Do not start new patients
<30 Stop Metformin
Diabetes Care 2011;34: 1431-1437
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Does Metformin Improve Outcomes in Patients With Type 2 DM and CHF ?
12,272 new users or oral diabetes agens between 1991-1996 reviewed. 1,833 had CHF
Of these patients treated for DM with CHF, 208 received metformin monotherapy, 773 were given sulfonylurea monotherapy and 852 received combination therapy.
Fewer deaths occurred in patients receiving metformin monotherapy (52% receiving sulfonylurea’s died, 33% receiving metformin monotherapy died, 31% receiving combination therapy died)
Diabetes Care 2005; 28: 2345-2351.
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Primary Care Urology
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A 84 yo man presents with hematuria. He had an episode last week, but has had hematuria for the past 4 days. He has had some hesitancy , frequency and nocturia for several years. Meds: ASA, MVI, omeprazole. A urinalysis is done which just shows RBC’s, no WBC’s. Cystoscopy shows no bladder malignancy. CT scan of the abdomen shows no renal lesions.
What do you recommend to help stop future hematuria?
A) Tamsulosin
B) Weekly dose of norfloxacin
C) Finasteride
D) Pyridium
E) Stop his aspirin
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Finasteride Treatment of Hematuria in Patients with BPH
Meta-analysis of multiple small studies for using finasteride for treatment of BPH associated hematuria
Use of finasteride resulted in decreased hematuria (OR .11, 95% CI: .06-.21, p<.05) over 12 months
Zhonghua Nan Ke Xua. 2006; 16 (8):726-729.
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How Finasteride Works to Decrease Hematuria
Randomized 30 patients to receive finasteride 5 mg vs placebo for 4 weeks prior to planned prostetectomy.
The suburethral and hyperplastic prostate specimens were examined for microvessel density (MVD).
MVD was the same in the hyperplastic areas for both, but was statistically lower in the suburethral area in patients taking finasteride ( 9.08 vs 13.94, p<.05)
Urol Int 2008; 80 (2): 177-80.
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What is Finasteride Good for?
Symptoms of BPH- marginal Decreasing risk of acute urinary
obstruction BPH related hematuria