Fairly simple case study/drug information question

[Ackj]

A case study from our drug information class:

"PH is a 42-year old man who was diagnosed with Type 2 Diabetes (Non-insulin dependent diabetes) about 2 years ago. He is currently controlling his diabetes with diet, exercise, and metformin 500mg BID. He has no prior history of cardiovascular disease, or hypertension. During his past doctor’s visit, his blood pressure was noted to be elevated (140/90). PH is only on metformin 500mg and has no known drug allergies.
Which product and dosage do you recommend?"

ADA diabetes guidelines have target bp <130/80. The pt is already doing the diet & exercise routine, so pharmacological intervention time. JNC7 has thiazides as first-line treatment, but this can cause worsening of hyperglycemia. ACEI and ARB both help with diabetic nephropathy and albuminuria. I've seen lisinopril used fairly frequently, although it's hard to find literature that does a head to head comparison of which ACEI is superior to another, making it hard to support. I know there's not going to be a clear-cut answer, but I'd like to make sure that I'm not missing anything major either.

Would Lisinopril 10mg daily be a suitable answer, or is there something better in your (more knowledgeable) opinions?

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[pharmwannebe2]

A case study from our drug information class:

"PH is a 42-year old man who was diagnosed with Type 2 Diabetes (Non-insulin dependent diabetes) about 2 years ago. He is currently controlling his diabetes with diet, exercise, and metformin 500mg BID. He has no prior history of cardiovascular disease, or hypertension. During his past doctor's visit, his blood pressure was noted to be elevated (140/90). PH is only on metformin 500mg and has no known drug allergies.
Which product and dosage do you recommend?"

ADA diabetes guidelines have target bp <130/80. The pt is already doing the diet & exercise routine, so pharmacological intervention time. JNC7 has thiazides as first-line treatment, but this can cause worsening of hyperglycemia. ACEI and ARB both help with diabetic nephropathy and albuminuria. I've seen lisinopril used fairly frequently, although it's hard to find literature that does a head to head comparison of which ACEI is superior to another, making it hard to support. I know there's not going to be a clear-cut answer, but I'd like to make sure that I'm not missing anything major either.

Would Lisinopril 10mg daily be a suitable answer, or is there something better in your (more knowledgeable) opinions?

I think Lisinopril would be the best choice also. Dont quote me but I have never seen a difference between ACEs.

 

[cycloketocaine]

A case study from our drug information class:

"PH is a 42-year old man who was diagnosed with Type 2 Diabetes (Non-insulin dependent diabetes) about 2 years ago. He is currently controlling his diabetes with diet, exercise, and metformin 500mg BID. He has no prior history of cardiovascular disease, or hypertension. During his past doctor’s visit, his blood pressure was noted to be elevated (140/90). PH is only on metformin 500mg and has no known drug allergies.
Which product and dosage do you recommend?"

ADA diabetes guidelines have target bp <130/80. The pt is already doing the diet & exercise routine, so pharmacological intervention time. JNC7 has thiazides as first-line treatment, but this can cause worsening of hyperglycemia. ACEI and ARB both help with diabetic nephropathy and albuminuria. I've seen lisinopril used fairly frequently, although it's hard to find literature that does a head to head comparison of which ACEI is superior to another, making it hard to support. I know there's not going to be a clear-cut answer, but I'd like to make sure that I'm not missing anything major either.

Would Lisinopril 10mg daily be a suitable answer, or is there something better in your (more knowledgeable) opinions?

Yes.

 

[confettiflyer]

lisinopril is fine...there's evidence/guidelines that differentiate between ACEI's in HF but not for plain ol' HTN. Renal protection is a bonus, so lisinopril it is.

 

[rx2010]

I agree with everyone as well. Lisinopril is fine, you're only limited to certain ACEIs when it comes to HF. Plus, all diabetics should be on an ACEI to help prevent diabetic nephropathy.

 

[eightball]

ACE..lisinopril is your best bet, need to protect those kidneys

 

[Ackj]

Plus, all diabetics should be on an ACEI to help prevent diabetic nephropathy.

My concern was that ARBs can also prevent diabetic nephropathy, so I couldn't really decide among an ACEI or ARB in any way besides what I've seen in common practice. Is there any logic behind the prevalence for ACEI?

 

[confettiflyer]

My concern was that ARBs can also prevent diabetic nephropathy, so I couldn't really decide among an ACEI or ARB in any way besides what I've seen in common practice. Is there any logic behind the prevalence for ACEI?

cost

 

[confettiflyer]

longer answer:

in theory ARBs will provide the same protection, but since the body of evidence for ACEI's is much larger by virtue of them being around so much longer, they're 1st line. Also, all ARB's are brand name up through the next year or two at least.

So 1st line ACEI, if they develop that pesky cough and don't like it, consider switching them to ARB at that point. Anyone remember if a pt gets angioedema on an ACEI, are they likely to get it w/ an ARB as well?

 

[rx2010]

longer answer:

in theory ARBs will provide the same protection, but since the body of evidence for ACEI's is much larger by virtue of them being around so much longer, they're 1st line. Also, all ARB's are brand name up through the next year or two at least.

So 1st line ACEI, if they develop that pesky cough and don't like it, consider switching them to ARB at that point. Anyone remember if a pt gets angioedema on an ACEI, are they likely to get it w/ an ARB as well?

They are less likely to get angioedema with ARBs, however since they are so closely related to ACEIs, it's recommended you don't take the risk of placing the pt on an ARB if they experienced angioedema with an ACEI.

 

[ForcedEntry]

Funny, the scenario presented looks oddly similar to one we had a few years back in school as a test question. The answer was none. Dx of HTN is not made w/ a single reading.

However, I know plenty of physicians that will start Tx anyway (we d/c it later about 30%(?) of the time) and I will gamble that your professor isn't trying to trick you.

Before starting an ACEI, you need to check his BMP. How's the patients' BUN/SCr/K? He's also >40 yo w/ a risk equivalent; start ASA 81mg QD. You also need to start a low-dose statin regardless of baseline level after checking his LFT's. I would also recommend CoQ-10.

 

[Sparda29]

longer answer:

in theory ARBs will provide the same protection, but since the body of evidence for ACEI's is much larger by virtue of them being around so much longer, they're 1st line. Also, all ARB's are brand name up through the next year or two at least.

So 1st line ACEI, if they develop that pesky cough and don't like it, consider switching them to ARB at that point. Anyone remember if a pt gets angioedema on an ACEI, are they likely to get it w/ an ARB as well?

Cozaar and Hyzaar went generic last week. To the OP, Lisinopril 10 mg sounds like a good start assuming that the BP reading was the 2nd time that it was read to be high, otherwise you wouldn't give the patient any medication and just recommend a low sodium diet for now.

 

[PumpkinSmasher]

Funny, the scenario presented looks oddly similar to one we had a few years back in school as a test question. The answer was none. Dx of HTN is not made w/ a single reading.

However, I know plenty of physicians that will start Tx anyway (we d/c it later about 30%(?) of the time) and I will gamble that your professor isn't trying to trick you.

Before starting an ACEI, you need to check his BMP. How's the patients' BUN/SCr/K? He's also >40 yo w/ a risk equivalent; start ASA 81mg QD. You also need to start a low-dose statin regardless of baseline level after checking his LFT's. I would also recommend CoQ-10.

A dude >50 w/a risk equiv......start the ASA 81mg

 

[Apteka]

umm.... diabetes treatment guidelines, anyone???

Not sure who wrote this (really poorly written) case (I HOPE it was not your faculty), but unless things have changed, standard of care would be that he would ALREADY be on an ACE-I AND Aspirin....

 

[confettiflyer]

Cozaar and Hyzaar went generic last week. To the OP, Lisinopril 10 mg sounds like a good start assuming that the BP reading was the 2nd time that it was read to be high, otherwise you wouldn't give the patient any medication and just recommend a low sodium diet for now.

Yeah see this is what I get for not working retail, haha...good to know about losartan & the thiazide combo.

Funny, the scenario presented looks oddly similar to one we had a few years back in school as a test question. The answer was none. Dx of HTN is not made w/ a single reading.

However, I know plenty of physicians that will start Tx anyway (we d/c it later about 30%(?) of the time) and I will gamble that your professor isn't trying to trick you.

Before starting an ACEI, you need to check his BMP. How's the patients' BUN/SCr/K? He's also >40 yo w/ a risk equivalent; start ASA 81mg QD. You also need to start a low-dose statin regardless of baseline level after checking his LFT's. I would also recommend CoQ-10.

As for not starting tx w/ the 2nd BP reading. He's got DM, he should be on an ACEI, 2nd reading be damned. Take a 2nd reading in the office to make sure he wasn't dashing down the street to get to his apt. I also wouldn't wait for labs either cuz I'm rogue like that...have them drawn in office and f/u w/ the pt if they've got K or BUN/SCr issues later.

Chances are, this person won't RTC for another month or more...start now, d/c later prn.

For some reason, I wouldn't apply this same logic to a statin. I'd wait for the lipid panel to come back before selecting a statin. If they're slightly above LDL goal, I'd pick lova or prava...if they're way above goal, kick 'em in the pants with atorva or rosuva.

 

[Quiksilver]

A case study from our drug information class:

"PH is a 42-year old man who was diagnosed with Type 2 Diabetes (Non-insulin dependent diabetes) about 2 years ago. He is currently controlling his diabetes with diet, exercise, and metformin 500mg BID. He has no prior history of cardiovascular disease, or hypertension. During his past doctor’s visit, his blood pressure was noted to be elevated (140/90). PH is only on metformin 500mg and has no known drug allergies.
Which product and dosage do you recommend?"

ADA diabetes guidelines have target bp <130/80. The pt is already doing the diet & exercise routine, so pharmacological intervention time. JNC7 has thiazides as first-line treatment, but this can cause worsening of hyperglycemia. ACEI and ARB both help with diabetic nephropathy and albuminuria. I've seen lisinopril used fairly frequently, although it's hard to find literature that does a head to head comparison of which ACEI is superior to another, making it hard to support. I know there's not going to be a clear-cut answer, but I'd like to make sure that I'm not missing anything major either.

Would Lisinopril 10mg daily be a suitable answer, or is there something better in your (more knowledgeable) opinions?

start lower dose on the ACE-I and titrate up. Protect against ARF. Lisinopril starts at 5 mg.

 

[Ackj]

umm.... diabetes treatment guidelines, anyone???

Not sure who wrote this (really poorly written) case (I HOPE it was not your faculty), but unless things have changed, standard of care would be that he would ALREADY be on an ACE-I AND Aspirin....

This isn't a therapeutics case (we haven't had therapeutics yet), its more of a "look for literature to support your answer" drug information assignment. As for the guidelines, I've been reading through http://care.diabetesjournals.org/content/33/Supplement_1/S11.full.pdf, is there a different/better one you'd recommend?

start lower dose on the ACE-I and titrate up. Protect against ARF. Lisinopril starts at 5 mg.

Clin Pharm, Micromedex, and Facts & Comparisons say for htn, start at 10mg/day and titrate to 20-40mg, unless creatinine clearance is <30 ml/min (in which case you would use 5mg). CHF tx also starts at 5mg.