sgd case 2b hypertension. patient information general information alu pihan 40/m chief complaint:...

SGD Case 2B

Hypertension

PATIENT INFORMATION

General Information

• Alu Pihan• 40/M• Chief Complaint: referred for “high-blood”

History of Present Illness

• 1 mo PTC– Consulted private MD– BP was 160/90– Given medication, did not comply– Lost to follow up

• Upon admission– Consulted for pre-employment check up– BP yesterday was 170/90

Review of Systems

• (-) Exertional dyspnea• (-) PND• (-) Orthopnea• (-) Palpitations• (-) Chest heaviness• (-) Edema• (-) Fever• (-) Cough• (-) Weight loss

• (-) Abdominal pains• (-) Nausea/vomiting• (-) Oliguria/dysuria• (-) BOVdizziness/

syncope/ seizures• (-) Headaches• (-) Paresis• (-) Paresthesia

Past Medical History

• Type 2 DM– Diagnosed: July 2008– Taking Metformin 500mg BID

Family Medical History

• (+) Hypertension: father• (+) Myocardial infarction: father

Personal/Social History

• (-) smoking• (-)alcohol• (-) drugs• Works as a sales manager • No food preferences

Physical Examination

• BP = 180/90• HR = 76 bpm• RR = 12/min• Temp = 37.1 °C• BMI = 22

Laboratory Results

• EKG– Left verntricular hypertrophy

• Chest X-ray– Cardiomegaly LV form

THERAPEUTIC MANAGEMENT

STEP 1Define the Patient’s Problem

Step 1: Define the Patient’s Problem

• Given the blood pressure of the patient, which is now 180/90, he is diagnosed with very high risk grade 3 hypertension with type 2 diabetes mellitus– Very high risk because: SBP ≥180, DM, EKG result

of LVH– Grade 3 HPN: SBP ≥180 or DBP ≥110


• Differential diagnoses– Secondary HPN: ruled out because of normal lab

findings– Essential HPN: ruled in because of family hx and

sudden onset– Drug induced HPN: metformin does not cause HPN


• Other lab work– Glucose tolerance test to check status of DM

STEP 2Specify the Therapeutic Objectives

Step 2: Specify therapeutic objectives

1) Lower blood pressure to <130/802) Prevent complications such as end-organ

damage3) Reduce risk factors4) Promote lifestyle change– Healthy eating habits, low salt, increase fruit and

vegetable, decrease in saturated fat and total fat; physical activity

STEP 3Choose the Appropriate Treatment

Step 3: Choose appropriate treatment

Efficacy Safety Suitability Cost

Calcium Channel Blockers

++++ ++++ ++++ +++

ACE Inhibitors

+++++ ++++ ++++ +++

Angiotensin Receptor Blockers

+++++ ++++ ++++ ++++

P-Drug Table: According to Drug Groups


• Beta blockers and thiazide diuretics– Not preferred because they may worsen insulin resistance and lead to

increased doses or numbers of antidiabetic agents• Angiotensin receptor blockers and ACE inhibitors

– Prevention and reduction of microalbuminuria and proteinuria • Lipid lowering agents (statins)

– Should also be considered because of CARDS trial, which indicated that diabetic patients benefit from having their lipids tightly controlled

• Information from 2007 Guidelines for the Management of Arterial Hypertension (Mancia, et al)


• Calcium Channel Blockers– Mechanism of action• Decrease the force of contraction of the myocardium

(negative inotropic effect)• Slow down the conduction of electrical activity within

the heart (negative chronotropic effect) lowering heart rate and the potential for heart block

Efficacy Safety Suitablilty CostAmlodipine ++++ ++++ +++ +++Nifedipine ++++ ++++ +++ +++++


• ACE Inhibitors– Side effects• Severe hypotension (in hypovolemic pxs due to

diuretics, salt restriction, or GI fluid loss)• ARF in patients with renal artery stenosis• Hyperkalemia• Dry cough• Sometimes wheezing and angioedema


• ACE Inhibitors– Drug interactions• K supplements, K-sparing diuretics • Hyperkalemia• NSAIDs impair hypotensive effects (block bradykinin-

mediated vasodilation)


• ACE Inhibitors– Contraindications• Pregnancy, Lactation, bilateral renal artery stenosis,

hypersensitivity, angioneurotic edema, hyperkalemia

Efficacy Safety Suitablilty Cost

Captopril ++++ +++ ++++ +++

Enalapril +++++ +++ +++++ +++++

Quinalapril ++++ +++ +++++ +++


• Captopril– Pharmacodynamics:• Onset: 0.5-1h• Peak: 1h• Duration: 6-12h

– Pharmacokinetics:• Rapidly absorbed, widely distributed• Metabolism (liver 50%, Urine 40-50%)• Half-life: 2h (increased in renal disease)

– 27 – 60 pesos/day


• Enalapril– Pharmacodynamics:• Onset: 0.5-1h• Peak: 1h• Duration: 6-12h

– Pharmacokinetics:• Well absorbed, 60%• Metabolism (Kidneys 60% enalaprilate, 20% enalapril)• Half-life: 12h (enalaprilate) – increased in renal disease

– 11 – 16 pesos per day


• Quinalapril– Pharmacodynamics:• Onset: 0.5-1h• Peak: 2-6h• Duration: 12-24h

– Pharmacokinetics:• Well absorbed• Metabolism (urine 60%, GI 37%)• Half-life: 2h

– 30 – 42 pesos per day


• Angiotensin Receptor Blockers– Main mechanism of action

• Antagonize the vasoconstrictor effects on smooth muscle and the secretory effects on zona glumerulosa of Angiotensin II at the Angiotensin II type 1 receptor

• leading to decreased peripheral vascular resistance– Preferred in patients with

• Heart failure, post-myocardial infarction, diabetic nephropathy, LVH, Atrial fibrillation, Metabolic syndrome

– Pharmacodynamics• Onset of action: 6 hours • Time to peak, serum: 1 hour (Losartan)• Duration: 24 hrs


• Angiotensin Receptor Blockers– Pharmacokinetics

• Well absorbed; systemic bioavailability is about 33%. T max is 1 h (losartan) and 3 to 4 h (metabolite).

• While C max of drug and active metabolite are equal, metabolite AUC is 4 times greater than that of losartan.

• Vd is 34 L (losartan) and 12 L (metabolite); highly bound to albumin. • Undergoes substantial first-pass metabolism by CYP-450 2C9 and 3A4

enzymes. • t ½ is 2 h (losartan) and 6 to 9 h (metabolite)• Renal Cl is 75 mL/min (losartan) and 25 mL/min (metabolite).• Total plasma Cl is 600 mL/min (losartan) and 50 mL/min (metabolite)• About 4% is excreted unchanged in the urine and 6% excreted as

active metabolite in urine.


• Angiotensin Receptor Blockers– Adverse effects

• Hypotension – most likely to occur in patients in whom the blood pressure is highly

dependent on angiotensin II, including those with volume depletion (e.g., with diuretics), renovascular hypertension, cardiac failure, and cirrhosis.

• Hyperkalemia– may occur with factors that alter K+ homeostasis (renal insufficiency,

ingestion of excess K+, & use of drugs that promote K+ retention) • Reduced renal function, associated with bilateral renal artery

stenosis and stenosis in the artery of a solitary kidney.• Teratogenic potential• Cough and angioedema- rare


• Angiotensin Receptor Blockers– Contraindications

• Pregnancy- 2nd and 3rd trimesters, hyperkalemia, bilateral renal artery stenosis

– Drug interactions• K-sparing diuretics, lithium, rifampin, trimethoprim, rifampin

– Suitability (Losartan)• 50 mg tablet, once daily • Convenient (easy to handle)• No contraindications and possible drug interactions in our patient

– Cost• Price range Php 15-43per 50 mg tablet• Duration of treatment: 2 weeks • Total: Php 210- 602


• If I were to choose one among CCBs ARBs and ACEIs (because of the patient’s compliance issues):– It is suggested (from the CPG) that in the presence of microalbuminuria or

diabetic nephropathy, treatment must start with or include a drug acting against the renin-angiotensin system. Our patient’s labs already indicated +1 proteins. Hence ACEIs and ARBs, having renoprotective effects, would be more beneficial to the patient. (CCBs eliminated)

– Between ACEIs and ARBs, I would (personally) choose ARBs since they have the same effects as ACEIs minus the side effect of coughing. However, ACEIs are cheaper. At this stage, the patient can be the one to decide as to which he prioritizes, the cost or the possible side effect. I could prescribe ACEI first, and warn the patient of possible side effects (esp. the cough that is not a side effect ARBs) and tell the patient to come back if the cough is not tolerable, in which case I would then switch to ARBs.

STEP 4Start the Treatment

Andrés Iniesta Luján, MD#8 Fuentebella Clinic, Albacete Tower, Castile-La Mancha St., Makati City

(02) 567 8910

Patient: Alu Pihan Date: July 20, 2010Address: Manila Age: 40

R/Enalapril maleate 5 mg tabletDisp #7Sig: Take 1 tablet x 7 days

Refill 0 times Dr. Andres Iniesta Lujan, MDPRC Lic. No. 88891PTR 15752A

Andrés Iniesta Luján, MD#8 Fuentebella Clinic, Albacete Tower, Castile-La Mancha St., Makati City

(02) 567 8910

Patient: Alu Pihan Date: July 28, 2010Address: Manila Age: 40

R/Enalapril maleate 10 mg tabletDisp # 30Sig: Take 1 tablet x 30 days

Refill 0 times Dr. Andres Iniesta Lujan, MDPRC Lic. No. 88891PTR 15752A

STEP 5Give Information, Instructions and Warnings

Step 5: Give Information, etc.

• Enalapril– Effects of the Drug• Why the drug is needed

– Because the patient’s hypertension, the presence of certain risk factors and organ damage, place him at a very high added risk for cardiovascular disease

– Enalapril is used alone or in combination with other medications to treat high blood pressure

– Enalapril is an angiotensin-converting enzyme (ACE) inhibitor– It works by decreasing certain chemicals that tighten the

blood vessels, so blood flows more smoothly and the heart can pump blood more efficiently


• Enalapril– Effects of the Drug• Which symptoms will disappear, which will not

– There will be reductions in the systolic and diastolic B.P. • When the effect is expected to start

– Peak plasma level after 3-4 hours• What happens if drug is taken incorrectly or not at all

– His hypertension will remain or worsen and he has a very high risk of acquiring cardiovascular disease


• Enalapril– Side Effects• Hypotension, dizziness, headache, and cough• Watch out for allergic reaction• How to recognize them

– Get emergency medical help if you have any of these signs: » An allergic reaction (hives)» Severe stomach pain» Difficulty breathing» Swelling of your face, lips, tongue, or throat


• Enalapril– Side Effects• How to recognize them

– Call your doctor at once if you have any of these serious side effects:» Feeling light-headed, fainting» Urinating more or less than usual, or not at all» Fever, chills, body aches, flu symptoms» Pale skin, easy bruising or bleeding» Fast, pounding, or uneven heartbeats» Chest pain» Swelling, rapid weight gain


• Enalapril– Side Effects• How to recognize them

– Less serious side effects may include:» Cough» Loss of taste sensation, loss of appetite» Dizziness, drowsiness, headache» Sleep problems (insomnia)» Dry mouth» Nausea, vomiting, diarrhea» Mild skin itching or rash


• Enalapril– Side Effects• How long will they continue

– Around 2 days (t1/2=11 hours)• What action to take

– See your doctor immediately– Stop taking drugs for the mean time


• Enalapril– Instructions• How the drug should be taken

– Initial dose is 5 mg daily. Maintenance dose is 10-20 mg daily. Monitor for at least 8 hours to avoid uncontrolled hypotensive response

– Should be taken with sufficient water– Enalapril can be taken with or without food


• Enalapril– Instructions• How the drug should be taken

– Do not take with alcohol as ACEI’s effects will be increased and might cause toxicity

– Do not take with sympathomimetics, NaCl, NSAIDS or COX-2 inihibitors as ACEI’s effect might be dampened

– Antacids will reduce ACEi bioavailability


• Enalapril– Instructions• Take this medication exactly as it was prescribed• Do not take the medication in larger amounts, or take it

for longer than recommended by your doctor• Follow the directions on your prescription label• When it should be taken

– Before, during or after meals, orally– Daily, once or twice a day with or without food– To help you remember to take enalapril, take it around the

same time(s) every day


• Enalapril– Instructions• How long the treatment should continue

– Enalapril controls high blood pressure but does not cure it– Continue to take enalapril even if you feel well– Do not stop taking enalapril without consulting the doctor– To be sure this medication is helping your condition, your

blood pressure will need to be checked on a regular basis– Your kidney or liver function may also need to be tested– Do not miss any scheduled visits to your doctor


• Enalapril– Instructions• How the drug should be stored

– 25-30 degrees Celsius or less, 2-3 years shelf-life– Must not be exposed to heat or direct sunlight


• Enalapril– Warnings• When the drug should not be taken

– During pregnancy (N/A for out patient), severe side effects are experienced

• Maximum dose: 40 mg/day• Why the full treatment course should be taken

– Enalapril controls high blood pressure but does not cure it


• Enalapril– Future Consultations• When to come back

– When starting out with the drug, come back for follow up after every 2-4 weeks, no changes in BP are observed

• When to come earlier– Side effects are observed

• What information the doctor will need for the next appointment– Routine blood pressure values when self-monitoring at home,

lab parameters for possible monitoring end-organ damage


• Enalapril– Patient Education• Ask the patient whether everything is understood• Ask patient to repeat important information• Ask if patient has any questions

STEP 6Monitor the Treatment

•Not more than 130/80 mm HgBlood Pressure

•80-120 mg/dl, before mealBlood sugar

•Dietary Approach to Stopping Hypertension•ComplianceLifestyle Modification

Therapeutic Goals

Passive Monitoring1. BP Apparatus within reach• It can be recommended that Mr. AP borrow/buy a BP

apparatus so he can monitor his BP– Proper use, reading of the PB app should be taught to AP and

his family– Regular monitoring should be logged (BP should be taken 2x a

day, one in the morning and in the afternoon, both sitting and standing to account for postural hypotension)

• If a BP app cannot be bought, going to the local health center for regular BP may also be done, but may be too tedious.

Passive Monitoring

2. Control of Blood Sugar• proper diet, exercise and compliance to

Metformin is recommended• FBS or RBS monitoring may be done in the

case where DM gets worse• having a food diary to recall and have a strict

control of the diet may also be done

Active Monitoring1. BP Control Evaluation• measure the BP in the clinic and check BP readings of

the past 2 weeks• if the BP is within target (not more than 130/80 mmHg),

treatment can be maintained• if BP is still elevated, treatment may be evaluated.– may change the dose, or add another drug (take into

consideration additional cost)– re-examine the non-pharmacologic aspects of the treatment:

compliance, diet, lifestyle, proper monitoring of BP

Active Monitoring

2. Blood Sugar levels• FBS may be monitored so as to monitor the

progression of the diabetes• FBS levels should be within 80-120mg/dl, before a

meal

3. Left Ventricular Hypertrophy Status• A repeat EKG may be done once the BP goal is

reached

Additional Reminders• If possible, avoid intake of drugs that raise BP

– Glucocorticoids, NSAIDs• Lifestyle Modification

– Smoking cessation – Sodium restriction, sodium chloride intake should not exceed 5g– Consume more meals rich in potassium, calcium and magnesium– Eat more fish and 4-5 servings of vegetables and fruits daily– Drink low fat milk

• Physical exercise – Moderate intensity exercises (endurance + resistance), 30-45 min/d

• Moderation of alcohol consumption– Limit alcohol consumption to 30 ml per day of a light alcoholic beverage

• Maintenance of ideal body weight

References• American Diabetes Association. Available at

<http://www.diabetichealthinfo.com/View.aspx?url=Article800>• August, Phyllis. Initial Treatment of Hypertension. N Engl J Med

2003 348: 610-617• National Institute of Health. JNC-7: Prevention, Detection,

Evaluation, and Treatment of High Blood Pressure. Available at <http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf>

• Schrier, Robert W., Estacio, Raymond O.Additional Follow-Up from the ABCD Trial in Patients with Type 2 Diabetes and Hypertension. N Engl J Med 2000 343: 1969

sgd case 2b hypertension. patient information general information alu pihan 40/m chief complaint:...

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