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A Case of Resistant Hypertension

A Case of Resistant Hypertension

A 67 year-old male with a history of hypertension, CAD (s/p PCI with stenting of RCA), hyperlipidemia, GERD, BPH, and DKD visits for an annual exam. He reports measuring home BP infrequently, but reports it is usually around 140-150/70-80 mmHg. At his visit, the following are measured:

PHYSICAL EXAM:

- BMI: 33 kg/m2
- BP: 188/94 mm Hg
- HR: 72 bpm
- Cardiac exam: regular rhythm, normal S1S2
- Lungs: clear; peripheral pulses symmetrical
- Absent carotid or abdominal bruits

LABORATORY RESULTS:

- eGFR: >60 ml/min/1.73 m2
- Serum K+: 3.6 mEq/L
- HbA1c: 6.1%
- Serum Na+: 142 mEq/L

MEDICATIONS:

- Losartan HCT: 100/25 mg qday
- Carvedilol: 12.5 mg bid
- Amlodipine: 5mg qday
- Clonidine: 0.1 mg qhs
- Atorvastatin: 10 mg qday
- ASA: 81 mg qday

After ordering an aldosterone-to-renin ratio (ARR) and 24-hour urine test for aldosterone, cortisol, sodium, and protein, it is decided to stop losartan hct and substitute it with lisinopril 40 mg qday and chlorthalidone 25 mg qam. Clonidine is also stopped and amlodipine is increased to 10 mg qday. At the patient’s 1 month follow up, his office BP (automated, 5-serial readings, unattended) is 165/92 mmHg. And the following is found during his exam:

LABORATORY RESULTS:

- Aldosterone/PRA: 11 ng/dL 0.6 ng/ml/hr
- 24-hr urinary aldosterone: 14 mcg
- 24-hr urinary sodium: 218 meq

Patient Case Question: Which medication change should be recommended?

A. Chlorthalidone 50 mg
B. Increase amlodipine to 20 mg qday
C. Increase carvedilol to 50 mg bid
D. Begin spirononlactone 25 mg qam

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Expert Commentary on the Case Conclusion

Balancing Glucose Control and Weight Gain

Balancing Glucose Control and Weight Gain

A 52 year old woman who was diagnosed with T2DM in 2001 is seen in consultation to improve glucose control. She has no hypoglycemic symptoms and her finger stick glucoses are 132-187 mg/dl AC and 156-398 mg/dl hs. She is frustrated by weight gain (17 lbs in past 11 months) and acknowledges stress eating due to financial concerns. She mentions that she is “too busy” to exercise and per her husband she snores and wakes up tired. She has previously declined a sleep study since she is “sure she doesn’t have sleep apnea.” Upon examination the following is documented:

MEDICAL HISTORY:

- Background diabetic retinopathy
- Diabetic polyneuropathy
- Diabetic nephropathy with microalbuminuria
- Obesity
- Hypertension
- Dyslipidemia
- Depression

FAMILY HISTORY:

- T2DM in mother and 3/5 siblings

SOCIAL HISTORY:

- She and husband own struggling business
- No tobacco, alcohol or illicit drug use

PHYSICAL EXAM:

- Tearful when discussing problems
- Generally and truncally obese
- Does not appear acromegalic or cushingoid
- BP: 128/82 mmHg
- HR: 78 bpm
- BMI: 43.4 kg/m2
- Feet: loss distal cold sensation; normal vibration and monofilament sensation

LABORATORY RESULTS:

- HbA1c: 9.7%
- Creatinine: 0.8 mg/dl
- GFR>60 mL/m/1.73m2
- K+: 4.5mM

CURRENT MEDICATIONS

- Lispro insulin 80 unit base dose with sliding scale AC
- Basaglar insulin 135 units bid
- Lisinopril 40 mg qd
- Atorvastatin 40 mg qd
- Sertraline 100 mg qd

PRIOR MEDICATIONS

- Metformin (GI upset)
- Liraglutide (dizziness)
- Empagliflozin (3 time/night urination)
- Pioglitazone (prior refusal due to concerns about bone fractures and weight gain)

Patient Case Question: How do you improve glucose control in this patient?

A. Before making changes, invite patient into office and administer her insulin and test insulin in the clinic to check adherence
B. Recommend gastric bypass immediately
C. Change insulin to U500
D. Recommend a psychologist and nutritionist

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Severe Hypertriglyceridemia

Severe Hypertriglyceridemia

A 45 year old man with known CHD S/P multiple PCIs/stents, T2DM since 1994, and hypertension for >20 years is hospitalized 5 months previously for chest pain. During his admission, the following is found:

LABORATORY RESULTS:

- TG: 2509 mg/dl
- HbA1c: 10.2%

MEDICATIONS:

- Gemfibrozil 600 mg BID
- DHA + EPA 2.5 g
- Atorvastatin 20 mg
- Glipizide 10 mg
- Metformin 850 mg BID

The patient was discharged on same medications plus a low fat diet and insulin glargine 10 units daily. His home glucose monitoring recordings have been in the 100-150 mg/dL range during several months of increasing insulin dosage. At his next clinic visit:

MEDICATIONS:

- Glargine 72 units daily
- Metformin 1 g BID
- Glipizide 10 mg BID
- Rosuvastatin 20 mg
- Gemfibrozil 600 mg BID
- Fish oils 1.6 g BID
- Clopidogrel 75 mg
- Aspirin 81 mg

PHYSICAL EXAM:

- Weight: maximum 280 lbs; patient had lost 14lbs since his hospitalization on a low fat diet
- BP: 140/68 mmHg
- BMI: 34.7 kg/m2
- Eruptive xanthomata on back and arms

LABORATORY RESULTS:

- TC: 259 mg/dL
- TG: 1965 mg/dL
- HDL-C: 35 mg/dL
- HbA1c: 7.8%
- AST, ALT: normal
- Creatinine: 1.0 mg/dL
- TSH: 1.6 mIU/L
- U/A albumin: – 789 mg/g

SOCIAL HISTORY:

- Eats fish approximately 1-2 times per month, whole grains approximately 1 serving a day, fruits and vegetables 4-5 servings a day; occasionally he eats out, but when he does, he eats salads
- No EtOH
- No tobacco
- Walks approximately 30 minutes daily, but this is difficult due to symptoms of peripheral neuropathy

Patient Case Question: What is the next best step in the management of this patient to reduce his triglyceride level?

A. No changes need to be made in the treatment of this patient.
B. Change gemfibrozil to fenofibrate
C. Add an ACE inhibitor or ARB
D. Recommend a low fat diet for 1-2 weeks and keep medications the same

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Challenges with High LDL-C Levels

Challenges with High LDL-C Levels

A 50 year old woman who is a busy mom working and going to school part time is referred for treatment of high cholesterol. Her weight has never been a problem but can vary by approximately 5 pounds; however, her weight is currently higher than her “goal weight.” The patient tries to eat healthy, but is not sure what diet changes to make. She likes desserts and has switched to portioned ice cream bars but eats 2 per day. The patient also does not enjoy exercise, but will occasionally walk on a treadmill. Her exam reveals:

MEDICAL HISTORY:

- High cholesterol over the last “few” years
- Depression and anxiety
- Not menopausal

FAMILY HISTORY:

- Mother has elevated cholesterol levels

PHYSICAL EXAM:

- BMI: 24.5 kg/m2
- Waist circumference: 83 cm
- BP: 132/85 mmHg

LABORATORY RESULTS:

- Cholesterol: 321 mg/dL
- TG: 115 mg/dL
- HDL-C: 73 mg/dL
- LDL-C: 223 mg/dL

MEDICATIONS:

- Alprazolam- 0.75 mg daily

Patient Case Question: How would you manage this patient?

A. Add a high dose statin
B. Review dietary intake
C. Add high intensity exercise
D. Measure Lp(a) levels

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Expert Commentary on the Case Conclusion