Case study: NSTEMI patient with NIDMM.

[Confusant]

Heya, I’m trying to solve a case study here. An overweight patient (BMI > 25) has experienced NSTEMI. He is now stabilized. The patient also has diabetes (type II) and renal failure. He is currently on biguanides. This is what I plan to give the patient for long term management of his heart failure:
Calcium channel blocker, nitrates, statins, aspirin, ace inhibitor
Will probably stop the biguanide as they are known to cause lactic acidosis in those with renal failure. Not sure what can I substitute it with? Surely not sulfonylureas because the patient is already obese.

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[Farmercyst]

Heya, I’m trying to solve a case study here. An overweight patient (BMI > 25) has experienced NSTEMI. He is now stabilized. The patient also has diabetes (type II) and renal failure. He is currently on biguanides. This is what I plan to give the patient for long term management of his heart failure:
Calcium channel blocker, nitrates, statins, aspirin, ace inhibitor
Will probably stop the biguanide as they are known to cause lactic acidosis in those with renal failure. Not sure what can I substitute it with? Surely not sulfonylureas because the patient is already obese.

What do his labs look like?

 

[Pharmavixen]

The benefits of metformin outweigh the very tiny risk of LA; what's his creatinine clearance? If RF is stable, you can give metformin down to 30mL/min.

How about a beta-blocker? They reduce mortality in HF, and metoprolol and carvedilol are hepatically cleared.

 

[Praziquantel86]

How is the renal function? What stage heart failure? Is he currently on any other medications/have any other conditions?

 

[Confusant]

What do his labs look like?

Lipid profile indicates hyperlipidaemia (TG, LDL increased, HDL decreased), no signs of infection, creatinine concentration in the body has increased above the normal range. Glucose concentration and HbA1C values are above the normal range.

I avoided beta blocker because it may mask signs of tachycardia in the event of hypoglycaemia.

The increased creatinine concentration in the body (130 micromol / L) is the only sign of renal failure.

Patient is not on other medications besides Metformin.

 

[Praziquantel86]

Lipid profile indicates hyperlipidaemia (TG, LDL increased, HDL decreased), no signs of infection, creatinine concentration in the body has increased above the normal range. Glucose concentration and HbA1C values are above the normal range.

I avoided beta blocker because it may mask signs of tachycardia in the event of hypoglycaemia.

The increased creatinine concentration in the body (130 micromol / L) is the only sign of renal failure.

Patient is not on other medications besides Metformin.

What are the exact values? And unless I'm converting wrong, 130umol/L is far from renal failure.

 

[Confusant]

That's just the concentration in the body. The normal range is up to 120 umol / L. I assumed that means there is a failure to clear creatinine?

 

[njac]

My theory on the BBs in diabetics is how often do you see a non-insulin dependent DM2 with hypoglycemia? Not very often.

 

[Confusant]

My theory on the BBs in diabetics is how often do you see a non-insulin dependent DM2 with hypoglycemia? Not very often.

Over-compliance with insulin injection is quite common, especially at times where patients overestimate their need for one.

My thoughts

 

[njac]

Over-compliance with insulin injection is quite common, especially at times where patients overestimate their need for one.

My thoughts

read the line you quoted more closely.

 

[Confusant]

read the line you quoted more closely.

True, apologies

 

[Praziquantel86]

A slightly elevated creatinine doesn't mean renal failure. Calculate a creatinine clearance and see what that tells you.

 

[Hernandez]

Heya, I’m trying to solve a case study here. An overweight patient (BMI > 25) has experienced NSTEMI. He is now stabilized. The patient also has diabetes (type II) and renal failure. He is currently on biguanides. This is what I plan to give the patient for long term management of his heart failure:
Calcium channel blocker, nitrates, statins, aspirin, ace inhibitor
Will probably stop the biguanide as they are known to cause lactic acidosis in those with renal failure. Not sure what can I substitute it with? Surely not sulfonylureas because the patient is already obese.

You do not give enough information to make any reasonable suggestions.
What is his ejection fraction and what is his NYHA class of heart failure?
What is his Creatine in mg/dL and what is his creatinine clearance.
What other comorbid conditions does he have
and what are his medicine allergies.

personally, I wouldn't use a CCB and nitrate as first line therapy. It sounds like the info you've given that he doesn't have true renal failure, so an ACE-I and a diuretic should be first line in a Diabetic, if he has a depressed ejection fraction, then a beta-blocker is also warranted.

If he truly has renal failure, then a sulfonylurea is not a better choice than metformin, as they you are actually more likely to see side effects such as prolonged hypoglycemia since they're are cleared via renal, Amaryl (if I remember correctly) does have more hepatic clearance than the rest of the sulfonyureas, but I wouldn't use it in a pt I wouldn't be willing to use metformin.

If all he has is mild CKD, the NSTEMI (CAD) and DM, I'd put him on a diuretic, ACE-I, ASA, Statin combo metformin/sulfonyurea if he needs better control.

If he has worsening CKD which for diabetics with creatine over 2.0, metformin and sulfonyureas are out and leaves you with insulin, and if the heart failure is uncompensated or requires chronic diuretics, then metformin is also out again. I'm fine with using metformin in a well compensated CHF pt with a creatinine of 1.5, but have a low threshold for discontinuing it for insulin.

 

[Confusant]

I will copy and paste all the information available to me:

Current medication:
Metformin

Current situation:
Stabilised after experiencing NSTEMI

Other comorbidities:
Diabetes Mellitus Type II

Lab data:
Eosinopil = Normal
Neutrophil = Normal
WBC = Normal
RBC = Normal
Troponin I = Elevated
HbA1C = 8%
Creatinine = 130 umol/L (Creatinine Clearance turns out to be [FONT=Arial, Helvetica, sans-serif]47.91, which indicates only a mild renal failure).
Cholesterol = 6.7 mmol/L
Glucose concentration = Above the normal range

LDL = 6.6 mmol/L
HDK = 1 mmol/L
Triglyceride = 2.0 mmol/L
Albumin/Creatinine ratio: 35 mg/mmoL

No information given on ejection fraction & heart failure class. Non-smoker, age 34, likes to drink. The above is all the information that I have been given

Now I need to prepare a treatment management for the patient.

 

[Farmercyst]

I will copy and paste all the information available to me:

Current medication:
Metformin

Current situation:
Stabilised after experiencing NSTEMI

Other comorbidities:
Diabetes Mellitus Type II

Lab data:
Eosinopil = Normal
Neutrophil = Normal
WBC = Normal
RBC = Normal
Troponin I = Elevated
HbA1C = 8%
Creatinine = 130 umol/L (Creatinine Clearance turns out to be [FONT=Arial, Helvetica, sans-serif]47.91, which indicates only a mild renal failure).
Cholesterol = 6.7 mmol/L
Glucose concentration = Above the normal range

LDL = 6.6 mmol/L
HDK = 1 mmol/L
Triglyceride = 2.0 mmol/L
Albumin/Creatinine ratio: 35 mg/mmoL

No information given on ejection fraction & heart failure class. Non-smoker, age 34, likes to drink. The above is all the information that I have been given

Now I need to prepare a treatment management for the patient.

Honestly, when did labs start coming in mmol/L?

 

[njac]

Honestly, when did labs start coming in mmol/L?

I'm guessing he's in the UK or maybe Canada. If you look you can find the conversion to mg etc

 

[Farmercyst]

I'm guessing he's in the UK or maybe Canada. If you look you can find the conversion to mg etc

Yeah, and if I get bored enough, I might. I probably should since we're doing our cardio module right now and it ties in nicely.

 

[Confusant]

Indeed I'm not from the United States.

Apologies for the unit confusion.

 

[Requiem]

Indeed I'm not from the United States.

Apologies for the unit confusion.

Don't apologize. The US should apologize for not adopting mmol/L.

Canada, Europe, New Zealand, Austrialia, etc all use mmol/L.

 

[Farmercyst]

Don't apologize. The US should apologize for not adopting mmol/L.

Canada, Europe, New Zealand, Austrialia, etc all use mmol/L.

I suppose we should also apologize for using Standard vs Metric and for driving on the right side of the road.

 

[Hernandez]

I suppose we should also apologize for using Standard vs Metric and for driving on the right correct side of the road.

Fixed it for you 😛

the only other thing I think I left off above would be aldactone if the ef is low as well, but I wouldn't use it if the EF wasn't depressed.

 

[njac]

Fixed it for you 😛

the only other thing I think I left off above would be aldactone if the ef is low as well, but I wouldn't use it if the EF wasn't depressed.

and no Spironolactone until your beta blocker is at its maximum dose. Not indicated until NYHA Class III and euvolemic.