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Old age issues; Treatment of hypertension and chronic kidney disease in diabetic patients

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  • Save Clinical M edicine and Diagnostics 2013, 3(3): 53-55 DOI: 10.5923/j.cmd.20130303.01 Geriatric Issue; Treatment of Hypertension and Chronic Kidney Disease in Diabetes Mellitus Patient Mohammed Zahid Iqbal1,*, Amer Hayat Khan1, Syed Azhar Sulaiman1, Mohammad Shahid Iqbal1,2 1Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains M alaysia 2Depart of Pharmacy Practice, School of Pharmacy, International M edical University, Bukit Jalil 57000 Kuala Lumpur, M alaysia Abstract Hypertension is a co mmon dilemma in patients with diabetes mellitus (DM) and increases the complications. Hypertension accelerates the progression of renal disease and may lead to end stage renal disease. A 70 years old, female, Malay, with a known h istory of type 2 d iabetes mellitus (DM), stage 2 severe hypertension (HTN) and newly diagnosed chronic kidney disease (CKD). Pat ient was ad mitted to ward o f Hospital Universiti Sains Malaysia (HUSM ) for radiocephalic fistula creation on patient left arm (L-RCF). Patient was admitted for L-RCF and waiting for the surgery on the following day. Blood pressure (BP) was way above the threshold value for pharmacolog ical t reatment. She was suffering fro m diabetes 20 years ago and hypertension developed 5 years later. Furthermore, patient was newly diagnosed with CKD and in need for d ialysis. Patient condition was worsening due to uncontrolled DM and she was on oral hypoglycemic agent. Surgery was postponed for a wee k and switched on Insulin plus ora l hypoglycemic and norma lized the BP by drug therapy. Patient was successfully underwent her surgery with minor pre-surgery comp licat ions and was treated with her anti-diabetic and antihypertensive med ications. Keywords Chronic Kidney Disease, Diabetes Mellitus, Geriatric, Hypertension, Radiocephalic Fistula 1. Introduction Hypertension is a common problem in patients with diabetes mellitus and a comorbid condition that enhances the risk of morb idity and mo rtality.1 In type I d iabetes, the incidence of hypertension increases from 5% to 70% at the duration of 10 to 40 years, and appears to be closely related to diabetic renal disease.1 In type 2 diabetes, hypertension is even more prevalent.2 Hypertension should be detected and treated early in the course of DM to prevent cardiovascular disease and to delay the progression of renal disease and diabetic retinopathy. Hypertension accelerates the progression of renal disease and may lead to end stage renal disease (ESRD). Good control of BP is therefo re important. The target BP should be < 130/80 mmHg for those with proteinuria of < 1g/24 hours and < 125/ 75 mmHg for those with proteinuria of > 1g/24 hours.3 2. Case Report A 70 years o ld female, Malay in race, with a known history of type 2 diabetes mellitus (DM ), stage 2 severe * Corresponding author: (Mohammed Zahid Iqbal) Published online at Copyright © 2013 Scientific & Academic Publishing. All Rights Reserved hypertension (HTN) and newly diagnosed chronic kidney disease (CKD). Patient claimed that based on self-monitoring BP measurement, the average systolic BP was 150-170 mmHg and diastolic BP was 80-60 mmHg. Patient was ad mitted in Hospital Universit i Sains Malaysia (HUSM) for radiocephalic fistula creation on her left arm (L-RCF). At the time of ad mission patient was nervous and on routine medicat ion. On the day next, patient complained of having trouble sleeping especially late night. Pat ient blood pressure (BP) at that time was skyrocketing which was 206/60 mmHg and her pulse rate (PR) was 79 beats/min. Fo r that condition, patient was on tablet Nifed ipine 10 mg stat and her BP post 1 hour was 166/60 mmHg, PR=68. Pat ient was being monitored closely for any symptoms or complications due to drop in her BP and Aspirin tablet was withheld (Table 1). Regarding uncontrolled diabetic condition patient was switched on Insulin with gliclazide oral. With one week interval, patient BP and diabetic level were normalized and was prepared for L-RCF surgery. Three hours post operation, the patient was co mfortable and being prescribed with Paracetamo l 1g tablet TDS. Patient was discharged with her current medications plus Paraceta mol 1g tablet TDS. Aspirin tablet was restart and her BP before discharged was 179/ 65 mmHg. 3. Discussion 54 M ohammed Zahid Iqbal et al.: Geriatric Issue; Treatment of Hypertension and Chronic Kidney Disease in Diabetes M ellitus Patient Table 1. Patient Medication Chart No. Name and Dosage form of drug St ren gth In dicat ion s Frequency 1. Tablet. Atenolol 2. Tablet Irbersart an+ Hydrochlorot hiazide 3. Tablet. Gliclazide 4. Tablet. Aspirin 5. Tablet. Acarbose 6. Tablet. Atorvastatin 7. Tablet. Felodipine 100mg Hypertension OD 300mg+12.5mg Hypertension OD 160mg Diabet es Mellit us BD 150mg Prophylaxis of CHD OD 100mg Diabet es Mellit us TDS 80mg Prophylaxis of CHD ON 5mg Hypertension OD *T ablet nifedipine 10mg stat was given on 2nd day of admission The exact hypotensive mechanism of β-b lockers is not known but may involve decreased cardiac output through negative chronotropic and inotropic effects on the heart and inhibit ion of renin release fro m the kidney. Atenolol has relatively long half-life and are excreted through urine; the dosage may need to be reduced in patients with moderate to severe renal insufficiency.4 The addition of lo w doses of a thiazide diuretic can increase efficacy significantly of Angiotensin II Receptor Blocker (ARB), wh ich is Irbersartan. In patients with type 2 diabetes and nephropathy, ARB therapy has been shown to significantly reduce progression of nephropathy.4 Calciu m Channel Blockers are useful add-on agents for BP control in hypertensive patients with diabetes. Limited data suggest that nondihydropyridines may have more renal protective effects than dihydropyridines.4 Aspirin was prescribed to high risk patients of Coronary Heart Disease (CHD) as a prophylaxis. The regimen was stopped a day before to allow surgery. Sa me as aspirin, it was prescribed as a prophylaxis for patients with CHD risk. These drugs were prescribed to control the blood sugar level of patient. The usage of these drugs needs to be monitored closely and the dose may need to be reduced due to her renal problem. Generally, pharmaco logical treat ment should be initiated in patients with diabetes when the BP is persistently >130 mmHg systolic and/or >80 mmHg diastolic.5 Tight BP control should take precedence over the class of antihypertensive drug used.6 This often will require oral combination therapy. There are suggestions that a lower target BP may be necessary to maximally protect against the development and progression of cardiovascular and diabetic renal d isease. In general, the systolic blood pressure (SBP) should be targeted to <130 mmHg and d iastolic blood pressure (DBP) <80 mmHg. The BP should be lowered even further to <125/75 mmHg in the presence of proteinuria of >1 g/24 hours.7 Before surgery, unstable BP and uncontrolled diabetes prolong the hospital stay and need to change the medicat ions. Insulin and tablet Nifedipine 10mg was provided to treat her problem. At the discharge time patient BP (196/64 mmHg) was high and concluded that patient was asymptomatic and no complications occurring. In such condition, Angiotensin Converting Enzy me Inhibitors (ACEI) is the drug of choice, if patient can tolerate, otherwise an Angiotensin receptor blocker (A RB) should be considered.8 Furthermore, in cases of slow progressing of nephropathy at the microalbuminuric stage or overt nephropathy stage in type 2 diabetic patients, ARB should be a better choice.9 Diuret ics can be used as initial therapy or added-on when monotherapy is inadequate. The lowest possible dose should be used to minimize adverse metabolic effects. However, adverse metabolic effects with higher doses of diuretics have also been reportedly reduced when used in combination with an Angiotensin Converting Enzy me Inh ibitors (A CEI) or an Angiotensin receptor blocker (A RB).7 4. Conclusions Present patient was successfully prepared to surgery with pre-surgery complications and was treated with anti-diabetic and antihypertensive medications. World Health Organization and mostly guidelines strongly recommended that before surgery, patient should switch on Insulin and control BP. Current case was switched on insulin and got better outcomes, where as Aspirin should be avoided. REFERENCES [1] Prisant, LM , Louard, RJ. Controversies surrounding the treatment of the hypertensive patient with diabetes. Current Hypertension Reports 1999; 1:512. [2] Epstein, M , Sowers, JR. Diabetes mellitus and hypertension. Hypertension 1992; 19:403. [3] Klahr S, Levey AS, Beck GJ, et al. The effects of dietary protein restriction and blood pressure control on the progression of chronic renal disease. N Engl J M ed 1994; 330:877-884. [4] Wells BG, Dipiro JT, Schwinghammer TL, Dipiro CV. Pharmacotherapy Handbook 7th Edition. Pharmacologic Treatment of Hypertension. 113-125. [5] Schrier RW, Estacio RO, Esler A, et al. Effects of aggressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopathy and strokes. Kidney Int 2002;61:1086-97 [6] Bakris GL, Williams M , Dworkin L, et al. Preserving renal function in adults with hypertension and diabetes: a Clinical M edicine and Diagnostics 2013, 3(3): 53-55 55 consensus approach. Am J Kidney Dis 2000;36:646-661. [7] Guidelines Subcommittee. 1999 World Health Organization International Society of Hypertension Guidelines for The M anagement of Hypertension. J Hypertens 1999; 17: 151 – 183. Diabetes and Nephropathy. N Engl J M ed 2004; 351: 1952 – 1961. [9] Ruggenenti P, Fassi A, Ilieva AP, et al. Preventing M icroalbuminuria in Type 2 Diabetes. N Engl J M ed 2004; 351: 1941 – 1951. [8] Barnett AH, Bain SC, Bouter P, et al. Angiotensin-receptor Blockade Versus Converting Enzyme Inhibition in Type 2

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