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If a patient has diabetes and hypertension and they were given propanolol would you be concerned?
Clinical opinion
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It wouldn't be my first choice of a anti-hypertensive agent, but I've seen it used. The patient will have to be more aware of hypoglycemic signs and symptoms, since those can be masked with beta-blockers.
Is the patient not on an ACE inhibitor?
it's really common. There is no contra indication between diabetes and beta blockers. A lot of patients can't tolerate ACEI/ARB. The dry cough is extremely common, and angioedma is rarer but far more serious.
Beta blocker is fine as an alternative. Especially in type 2 diabetes what still have some pancreatic function (using smaller insulin doses). So don't freak out. At most counsel on it. If they've been on it, I wouldn't normally even say anything.
Beta blocker is fine as an alternative. Especially in type 2 diabetes what still have some pancreatic function (using smaller insulin doses). So don't freak out. At most counsel on it. If they've been on it, I wouldn't normally even say anything.
I wouldn't really be concerned, but I'd definitely make sure that the patient was counseled properly. (i.e. not "do you have any questions?" like most walgreens patients get) It really depends on a lot of things though (other comorbidities, HR, etc). I probably wouldn't talk to the doc about it unless I spoke with the patient and found out they had asthma or heart block.
I think "at most counsel on it" is a horrible piece of advice. You should always counsel on it...what happens when you don't and your patient gets hypoglycemic and doesn't recognize it because you failed to mention the masking effects?
I think "at most counsel on it" is a horrible piece of advice. You should always counsel on it...what happens when you don't and your patient gets hypoglycemic and doesn't recognize it because you failed to mention the masking effects?
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dangerdog was apparently dropped a lot as a wee one. But don't worry. At most counsel on it.
Basically take his post, assuming everything is completely wrong, and you'd be in good standing.
Hahaha. I'm already doing a better job than my pharmacists at the walgreen i work at. They never counsel on this type, they just override the computer. I actually counsel more than they do. But I limit those to new scripts that have these problems, after all they get mad at me if I fall behind. If it's a refill, I just go, "you have any question" route. There is what you like to do, and what you could do realistically. All my professors harps on MTMs, where all my pharmacists laugh in my face when I say we should.
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propanolol can cause blood sugar levels to fall so would you advice the patient to have some sugar source with them at all times or would you also tell them to have their dose reduced.
not really. beta blockers don't affect blood sugar much. They primary have the potentially mask the symptom of hypoglycemia, making onset less detectable. So it's a caution. All diabetics should carry sugar with them anyway.
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But if their blood sugar drops, you can just give them something sweet, like cande-sartan😉
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more then likely the patient should be monitoring blood glucose if they are adding glycemic control to their daily medications (which may include propanolol) so they will be aware of being hypoglycemic. Or if the propanolol is being added/adjusted to a regimen, make a note to maybe watch their blood sugars a little more closely with a meter. then adjust when sugars are low. Food for thought
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why are we going propanolol
no one has thrown out cardio-selective beta blockers?
no one has thrown out cardio-selective beta blockers?
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There is a lack of information about the patient regarding other comorbidities and past failed treatments, if any. I don't see any point in using propranolol if that is the first agent in this case used to decrease blood pressure. There are other medications that should be used first line, and certainly better beta-blockers that could be used if beta-blocker therapy is warranted.
But to be fair, the patient is on propranolol currently, so I'm going to assume the conversation thus far has been about propranolol specifically since that is what was dispensed to the patient.
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cirrhosis, with portal hypertension/varices is an indication.... so knowing how much america's youth drinks, non-selective may be come the new rage in Pharmaceuticals
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Actually, beta blockers do block the response of glycemic levels back to normal during hypoglycemia. But like you said, it probably isn't that clinically important, just a caution. Propranolol is worse at this than the B1 selective agents.
Here's a reference, BMJ 1967;2:447....nice and current 🙂
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So we got an alcoholic, hypertensive diabetic patient now?
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I thought they were selective for B1?
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Yeah that's what I meant, key stroke error. Will correct. You are right it's B1.
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Sweet! I actually remember something after all. I win!
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who said life is supposed to be easy
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you'd go nadolol if you had portal hypertension....
don't know why you're scrambling to come up with a random scenario where it might fit - this 4 word case study is a bit ******ed to begin with. although at least its not UK vs US pharmacists again.
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i didn't randomly scramble to find a fit. you asked why we could have propanolol, and I gave you a reason why we would, its not like we are dealing with a rare acute promyelocytic leukemia, its cirrhosis, its not a completely random disease state
But while we are on the topic, we learned that propanolol and nadolol are both good choices, why do you prefer (im assuming you preferred) nadolol over propanolol. The idea is to pick a non-selective agent.
Nadolol isn't metabolized by the liver and showed fewer side effects in trials evaluating beta-blockers in portal hypertension. That's assuming that this hypothetical diabetic patient still has decent kidneys, of course.
I know, it inhibits the sympathetic response, slowing the recovery from hypoglycemia. But he said it would cause a BG drop, which it does not. 🙂
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you got it
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to quote a pharmacologically inclined friend of mine:
"Well..lets look at what propranolol does...it's a non selective beta blocker...most people think...ok...lungs...heart...but they forget about the happy little beta-3 receptor...which regulates lipolysis. Inhibit lipolysis...potentially cause hypoglycemia. "
Except beta blockers do not cause decrease BG clinically. Pharmacology doesn't equal clinical results, as we are well aware. Besides, beta blockade is more likely to increase blood surgar than decrease it.
Because you are blocking sympathetic system, decreasing insulin release, hence hyperglycemia. This applies for the more common type 2 diabetes of course. Ah, the danger of thinking only in 1 signal pathway.
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True. That's the one noticeable sign of hypoglycemia that beta-blockers won't mask.
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Except beta blockers do not cause decrease BG clinically. Pharmacology doesn't equal clinical results, as we are well aware. Besides, beta blockade is more likely to increase blood surgar than decrease it.
http://emedicine.medscape.com/article/813342-overview
I've seen examples of beta blockers, especially toxicities, causing hypoglycemia.
No idea why you've got such a smug view on something that I'm not confident you've had exposure on outside of a classroom. Same goes for your "most patients don't tolerate ACE inhibitors and dry cough is extremely common" comment.
Your link is talking about beta blocker overdose toxicity. Irrelevant in this discussion.
here:
http://www.theannals.com/cgi/content/abstract/19/4/246
"In insulin-dependent diabetics, beta-blockers can prolong, enhance, or alter the symptoms of hypoglycemia, while hyperglycemia appears to be the major risk in noninsulin-dependent diabetics. beta-blockers can potentially increase blood glucose concentrations and antagonize the action of oral hypoglycemic drugs."
My personal take, beta blocker do not usually have a significant impact on blood sugar levels clinically. Diabetics on beta blockers y just need to watch out for the masking of the symptoms, instead of worrying about beta blockers raising or lowering their BS.
Edit: here is the ACEI dry cough side effect: "Although estimates vary, 20% or more of patients who receive ACE inhibitors develop a dry cough, sometimes severe enough to require discontinuation of the drug."
http://www.medscape.com/viewarticle/484537_2
PS: If you want to quote me, don't lie. I never said "most patient do not tolerate ACEI." Please don't lie in try to make a point. I intern in both hospital ED as well as in Retails. While I am no expert in the field, I have seen enough patients complaining about dry coughs to know it's a very common side effect, and often warrant a change in tx. You need to get off the idea that you are somehow better than others, and try to talk down to anyone who disagrees.
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Maybe the pt has stage fright too.
