Patient Information

General Information

• Alu Pihan

• 40/M

• Chief Complaint: referred for “high-blood”

History of Present Illness

• 1 mo PTCo Consulted private MDo BP was 160/90o Given medication, did not complyo Lost to follow up

• Upon admissiono Consulted for pre-employment check upo 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 DMo Diagnosed: July 2008o 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

• EKGo Left ventricular hypertrophy

• Chest X-rayo Cardiomegaly LV form

Therapeutic Management

Step 1Defining the patient’s problem

Step 1: Define the Patient’s Problem

• Grade 3 essential hypertension, very high risk, complicated by type 2 diabetes mellitus, to consider diabetic nephropathyo Grade 3 HPN: SBP ≥180 or DBP ≥110o Very high risk: SBP ≥180, DM, EKG result of LVHo Diabetic nephropathy: mild proteinuria

Step 1: Define the Patient’s Problem

• Differential Diagnoseso Secondary HPN: ruled out because of normal lab findingso Essential HPN: ruled in because of family history and sudden

onseto Drug induced HPN: Metformin does not cause hypertension

Step 2Specifying the therapeutic objectives

Step 2: Specify therapeutic objectives

• General objective: to achieve maximum reduction in blood pressure with decreased risk of cardiovascular morbidity and mortality due to hypertension

• Specific objectives– Target BP <130/80– Prevent further end-organ damage– Reduce risk factors– Control underlying co-morbidity– Patient education

Step 3Choosing the appropriate treatment

Pharmacologic

Non-pharmacolo

gic

Treatment Approach

Drug Class

Efficacy Safety Suitability

Cost

ACE inhibitors

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

ARBs ++++ ++++ ++++ +++

Calcium Channel Blockers

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

Diuretics ++++ +++ +++ ++++

Beta-blockers

Alpha-blockers

++ ++ + +

Combi Drugs: ACEi with CCB

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

Angiotensin Converting Enzyme Inhibitor

Efficacy Safety Suitability CostAngiotensin Converting Enzyme Inhibitor

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

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

25mg PO TIDPhp 58.68 daily

Enalapril

++++ ++++ ++++ ++++10mg PO once

dailyPhp 29.60 daily

Angiotensin Receptor Blocker

Efficacy Safety Suitability CostAngiotensin Receptor Blocker

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

Losartan ++++ ++++ ++++++++

P16.80/day 50 mg OD

Valsartan ++++ ++++ +++++++

P44.53/day80 mg OD

Calcium Channel Blockers

Efficacy Safety Suitability Cost

Amlodipine PO 5mg OD ++++ ++++ ++++ PhP 22.85

(Norvasc)

Nifedipine PO 30mg OD

++++ +++ ++++PhP 30.06 (Calcibloc

OD)

DiureticsEfficacy Safety Suitability Cost

Loop diuretics: Furosemide

+++ + +

++P9.39/ 40 mg

tab10-40 mg 2x

dailyP18.27 per day

Thiazide:Hydrochlorothiazide

++++ +++ +++

++++P3.25/ 12.5 mg

tab12.5-50 mg

dailyP3.25 per day

Aldosterone Antagonist: Spironolactone ++ ++ ++

+++11.59/ 25 mg

tab25-50 mg dailyP11.59 per day

Efficacy Safety Suitability Cost

Alfadil XL ++ + Contraindicated

Terazosin HCl

Conmy +++ ++++ ++++ +++44.50/tab

Hykor +++ ++ +++ +++41.66/tab

Hytrin +++ +++ +++ ++62.00/tab

Prazosin ++ ++ ++

Alpha-blockers

Beta-blockersEfficacy Safety Suitability Cost

Metoprolol (Rite MED)

++++ +++ ++ ++++Php 4.5-18/day

Propanolol (Rite MED)

++++ +++ ++ ++++Php 7/day

Carvedilol (Betacard tab)

++++ +++ ++ +++Php 14-28/day

CombiFormulation: ACEi + CCB

Efficacy Safety Suitability CostACEI + CCB

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

Drug Class

Efficacy Safety Suitability

Cost

ACE inhibitors

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

ARBs ++++ ++++ ++++ +++

Calcium Channel Blockers

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

Diuretics ++++ +++ +++ ++++

Beta-blockers

Alpha-blockers

++ ++ + +

Combi Drugs: ACEi with CCB

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

Final Choice of Medications

ACEi Class Enalapril

CCB Class

Amlodipine

Step 4Prescription Writing

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

(02) 567 8910

Patient: Alu Pihan Date: July 22, 2010Address: Manila Age: 40

R/Enalapril maleate 10 mg tablet #30

Sig: Take 1 tablet before a meal, once a day, for 30 days

Amlodipine besylate 5 mg tablet #30 Sig: Take 1 tablet before a meal, once a day, for 30

days

Refill 0 times (signed)

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

Step 5Information, Instructions, Side Effects, Warnings

Step 5: Give Information, etc.

• Effectso 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

Step 5: Give Information, etc.

o 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– Effects can be seen after 4-5 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

Step 5: Give Information, etc.

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

Step 5: Give Information, etc.

• Enalaprilo Side Effects

• How long will they continue– Around 2 days (t1/2=11 hours)

• What action to take– See/Call your doctor immediately– Stop taking drugs for the mean time

Step 5: Give Information, etc.

• Instructionso How the drug should be taken

• Enalapril– 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

Step 5: Give Information, etc.

• Instructionso How the drug should be taken

• Amlodipine– Initial dose is 2.5-5 mg, once daily. Maintenance

dose is 5-10 mg, once daily. Monitor for at least 8 hours to avoid uncontrolled hypotensive response

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

Step 5: Give Information, etc.

• Instructionso How the drugs 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

Step 5: Give Information, etc.

• 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

Step 5: Give Information, etc.

• Instructions• How long the treatment should continue

– Drugs control high blood pressure but does not cure it

– Continue to take drugs even if you feel well– Do not stop taking drugs 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

Step 5: Give Information, etc.

• Instructionso 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

Step 5: Give Information, etc.

• Warningso When the drug should not be taken

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

o Maximum dose• Enalapril 40 mg/day• Amlodipine 10 mg/day

o Why the full treatment course should be taken– The drugs control high blood pressure but do not

cure it

Step 5: Give Information, etc.

• Future Consultationso 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– Serious side effects are observed as well as

allergic reactions• 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

Step 5: Give Information, etc.

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

Step 6Monitoring the Treatment

•Not more than 130/80 mm Hg

Blood Pressure

•80-120 mg/dl, before meal

Blood sugar

•Dietary Approach to Stopping Hypertension•Compliance

Lifestyle Modification

Therapeutic Goals

Passive Monitoring

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

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

familyo 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 Monitoring

1. 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.o may change the dose, or add another drug (take into consideration

additional cost)o 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 BPo Glucocorticoids, NSAIDs

• Lifestyle Modificationo Smoking cessation o Sodium restriction, sodium chloride intake should not exceed 5go Consume more meals rich in potassium, calcium and magnesiumo Eat more fish and 4-5 servings of vegetables and fruits dailyo Drink low fat milk

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

• Moderation of alcohol consumptiono 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