Practical Pearls for Primary Care. Evaluation and Treatment of Hypertension.

Practical Pearls for Primary Care

Evaluation and Treatment of Hypertension

A 58 yo man is diagnosed with hypertension. His BP’s are 160/96, 160/100, and 158/96 on 3 outside readings. He has been on a low sodium diet and he is not obese.

PMH- hyperlipidemia, GERD and gout. What would be the most appropriate treatment?

A) Low salt diet and exercise

B) Hydrochlorathiazide

C) Doxazosin

D) ACE inhibitor

When Thiazides Are Not A Good Choice

History of Gout Creatinine > 1.6 Lithium use

Diuretic Choice

Strongly consider chlorthalidone Long acting, great data Major drawback has been hypokalemia

Pearls in the Treatment of Hypertension

Remember when not to use hydrochloathiazide: renal insufficiency , gout

Chlorthalidone has longer half life, better efficacy than HCTZ

Spironolactone avoids hypokalemia, avoid in renal insufficiency, be careful if patient on an ACEI or ARB. Remember gynecomastia

Losartan can lower uric acid

A 60 yo man presents for follow-up of hypertension. He has been taking medication (Lisinopril) for the past 3 months. His most recent outside blood pressure readings are 156/94, 150/96, 158/92. PMH: Type 2 DM, GERD, depression. Meds: Lisinopril 20mg qd, Rabeprazole 20mg qd, Sertraline 50 mg qd, Glyburide 10 mg qd.

What do you recommend? A) No changes in therapy B) Increase Lisinopril to 20 mg BID C) Add Hydrochlorathiazide 12.5 mg qd D) Add Amlodipine (Norvasc) 5mg qd E) Add Clonidine .1mg BID

Combination Therapy

Low doses of thiazide can be very effective in combination with ACE inhibitors (12.5 mg of thiazide)

Thiazide ACE combination can be further enhanced by moderate dietary salt restriction

ACE/Amlodipine combination may have CV benefi slightly better than ACE/diuretic in high risk diabetic paients

A 58 yo woman is seen for treatment of hypertension. She has not ever had good control of her hypertension since treatment was started 2 years ago. She has been taking her medications faithfully. Meds: Felodipine (Plendil), Atenolol , Clonidine, and Losartan (Cozaar). On exam her BP is 200/106 P-55.Labs- BUN 30, Cr 2.0, Na 137, K 4.0. ECG- LVH

What would you recommend?

A) Increase felodipine from 10mg a day to 10mg BID

B) Increase losartan from 50mg BID to 100mg BID

C) Add hydrochlorathiazide 12.5 mg qd

D) Add hydrochlorathiazide 25 mg qd

E) Add furosemide 40 mg BID

Refractory Hypertension Occurs in 5% of hypertensive patients Always carefully evaluate for medication

adherence. Worse with increasing obesity Think of secondary causes Sleep apnea Ingestion of substances that interfere with

treatment (especially NSAIDS)

Treatment of Refractory Hypertension

Most have too much volume. Furosemide extremely useful, especially if renal insufficiency present

Strongly consider using spironolactone Simplify regimens if possible to improve

adherence

AHA Recommendations For Treatment of Hypertension

Indication BP goal Initial therapy B Blocker

Low risk <140/90 ACE/CCB/Thi NoHigh risk <130/80 ACE/CCB/Thi NoWith CAD <130/80 BB and ACE YesCHF < 120/80 BB/ACE/Aldo Yes Diuretics

How Can You Tell What Kind Of Headache It Is?

A 29 yo woman is evaluated for headaches. She reports having headaches about twice a month. She feels pain behind her right eye and frequently pain on her forehead. Her headaches often get better with 550 mg of Naprosyn. She has never had visual problems or nausea with her headaches. The headaches are worse with exercise. About once a month the headache is bad enough to force her to leave work early.

What is the Most Likely Type of Headache?

A)Migraine

B)Cluster

C)Muscle tension

D)Nitrate headache

Clinical Features of Tension Type Headache

Mild Headache Often described as tightness, vice like Neck to forehead can be involved Often helped by NSAIDS Worse during times of stress Not disabling

Clinical Features of Migraine Headaches

Family history common Pulsating quality Worse with activity Mild to Severe in intensity Can be disabling History of motion sickness common Nausea, photophobia, phonophobia may

occur

Diagnosing Migraine POUNDing Pneumonic Pulsating Duration 4-72 hOurs Unilateral Nausea DisablingIf 4 criteria met LR is 24 for migraineIf 3 met LR 3.5If 2 or fewer LR.41

JAMA 2006: 296: 1274-1283

A 29 yo woman presents for evaluation. She reports that she has frequent headaches over the past 12 months that include pressure pain on her forehead, under her eyes and over her cheeks. She usually has nasal congestion as well. She has not had any fevers or purulent nasal discharge. What is the most likely problem?

A) Cluster headaches

B) Migraine headaches

C) Sinus headaches

D) Tension headaches

“Sinus” Headaches Are Usually Migraine Headaches

2991 patients screened who reported at least 6 headaches during the previous 6 months self diagnosed or physician diagnosed as sinus headaches

88% of these patients met IHS criteria for migraine HA (80%) or migrainous criteria (8%).Most common sx patients reported were sinus pressure (84%), sinus pain (82%) and nasal congestion (63%)

Arch Intern Med 2004;164 (16): 1769-1772

Sinus, Allergy and Migraine Study

100 patients recruited who believed they had sinus headaches. All received a detail history and PE and given headache diagnosis based on HIS criteria

Final diagnosis were as follows: Migraine with or without aura 52%, probable migraine 23%, chronic migraine with medication overuse HA 11%, nonclassifiable HA 9%. 76% of migraine patients reported pain in the distribution of the 2nd division of the trigeminal nerve and 62% experienced bilateral forehead and maxillary pain with their HA’s.

Headache 2007;47:213-224

Treatment of Sinus Headache as Migraine: The Diagnostic Utility of

Triptans To determine the response rate to triptans in

alleviating “sinus headache” in patients with endoscopy and CT negative sinus exams

Prospective study of patients with physician or patient self diagnosed sinus headaches with negative workup all treated with triptans

54 patients enrolled, 38 completed follow up. 31 patients (82%) had significant reduction in headache pain with triptan use, 35 (92%) had a response to migraine directed therapy.

Laryngoscope 2008;Dec; 2235-2239.

Tip Offs That a Headache is Not of Sinus Orgin

Absence of fever Absence of purulent drainage Chronicity

Frequency of Headache Types

Tension Type – Most common

Migraine - Common

Cluster - Rare

Treatment Pearls for Migraine

Role of Metoclopramide

Good efficacy when combined with NSAID. Equivalent to sumatriptan oral if patient has nausea.

My boost effect of oral triptan or other oral migraine treatments

Metoclopramide vs Hydromorphone

Retrospective cohort study to evaluate metoclopramide vs hydromorphone for initial ED treatment of migraine

200 patients, 51 received IV or IM hydromorphone, 95 received IV metoclopramide and 54 received a different medication.

Using a 1-10 pain scale, mean pain scale reductions were 2.3 for hydromorphone, 3.7 for metoclopramide and 2,8 for all other meds (p<.001).

Less rescue meds and faster ED discharge with metoclopramide

J Pain 2008;9 (1): 88-94.

Sumatriptan + Naproxen Sustained pain free response 2-24 hours, the

combination is superior to either drug by itself (p<.01) . Dose used 85 mg sumatriptan/500mg naproxen (1)

In patients with poor prior response to triptans, the combination was significantly more effective than placebo (p<.001) (2)

1)JAMA 2007;297:1443-1454.

2) Headache 2009;49:971-982.

Oral treatment protocol for moderate to severe HA

NSAID + motility drug (Metoclopramide)

no relief

Oral triptan

no relief

Oral narcotic

no relief

ER/office visit for IV therapy

Infectious Disease Pearls

A 55 yo man presents with discomfort in his leg and swelling. He has no chronic medical problems. He has had problems with athlete’s foot. Labs: WBC 12,000

VS : T- 37.5 BP 130/70 P 88

What do you recommend?

A. Metronidazole

B. Ciprofloxacin

C. TMP/Sulfa

D. Vancomycin

E. Cefazolin

The Role of A-Hemolytic Streptococci in Causing Diffuse, Nonculturable Cellulitis

- All patients admitted to one hospital with diffuse cellulitis over a 3 year period were enrolled. 179 were studied

- All patients had serologic studies for exposure to streptococci, response to antibiotics were recorded

- 131 positive for strep, 48 negative- 71/73 (97%) evaluable patients with positive strep

studies responded to B lactams, 21/23 (91%)with negative studies responded to B lactams (overall respones rate 95%)

Medicine 2010;89: 217-226

Clinical Practice Guidelines for Treating MRSA

- For outpatients with nonpurulent cellulitis

(no purulent drainage or exudate, no abscess) empirical therapy for infection due to B hemolytic streptococci is recommended.

- Coverage for CA-MRSA is recommended in patients who do not respond to B lactam therapy.

Clin Inf Dis 2011; 52(3):e18-e55

A 22 yo woman presents with dysuria, frequency and hematuria. No fever, chills or flank pain. Allergies:sulfa. Ua- 20-30 WBC’s/HPF

What do you recommend?

A. Urine culture

B. TMP/Sulfa

C. Ciprofloxacin

D. Nitrofurantoin

E. Cephalexin

International Practice Guidelines for Uncomplicated Cystitis/Pyelonephritis in Women

Cystitis recommended antibiotics- Nitrofurantoin 100mg BID X 5 days- TMP/Sulfa DS BID X 3 days (if resistance

in the community <20% and not used in the past 3 months)

- Fosfomycin 3 gram single dose

Clin Inf Dis 2011; 52(5): e 103-120

International Practice Guidelines for Uncomplicated Cystitis/Pyelonephritis in Women

Pyelonephritis- Always get a urine culture/sensitivities- Ciprofloxacin 500 mg BID (with IV initial dose if

appropriate) if community resistance to FQ <10%- If >10% FQ resistance, start with 1 gm ceftriaxone

dose or 24h dose of aminoglycoside- Further treatment based on urine sensitivities

Clin Inf Dis 2011; 52(5): e 103-120

A 66 yo woman is seen for fevers and diarrhea. Had dental surgery 6 months ago and was given a 7 day course of amox/clav. Afterwards she developed fever and diarrhea and was dx with C diff. She has had 2 more recurrences since treated with vancomycin each time.Meds : Citalopram,omeprazole, zolpidem.

Her stool returns positive for C diff . What do you recommend?

A. Metronidazole X 2 weeksB. Vancomycin X 1 month (with taper)C. CholestyramineD. Fecal transplant

Fecal Transplant for Recurrent C Difficile Infection

- 19 patients with recurrent CDI treated with fecal transplant delivered through colonoscope

- 18 patients had immediate response with resolution. One patient recovered after a 2nd transplant. Three had recurrences after receiving antibiotics.

J Clin Gastroenterology 2010;44: 567-570.

A 36 yo woman presents with facial pain, congestion and low grade fevers for the past 7 days. On exam, T 37.9, P 80. Tenderness over left maxillary sinus.

What do you recommend?A) No antibiotic treatmentB) AmoxicillinC) Amoxicillin/ClavulanateD) AzithromycinE) Levofloxacin

IDSA Guidelines for Treatment of Rhinosinusitis

Treat with antibiotics at 10 days of symptoms, treat earlier if A)T >39 AND purulent nasal discharge or severe facial pain B) “Double sickening”

Amoxicillin/Clavulanate the preferred antibiotic Do not use Azithromycin or TMP/Sulfa Quinolones or Doxycycline alternate choices for PCN

allergic patients

Clinical Infectious Diseases 2012;54(8):1041–5

Using Common Drugs

A 60 yo man returns for annual follow up. He has a history of hyperlipidemia and is being treated with atorvastatin 40 mg daily. His other medications include sertraline, omeprazole and vitamin D. What would you recommend?

A)Check fasting lipids

B)Check fasting lipids , CPK

C)Check fasting lipids, CPK, ALT,AST

D)Check fasting lipids, AST,ALT

Is There Any Benefit to Checking Liver Enzymes in Statin Treated Patients?

408 patients undergoing statin treatment with at least one lab test (AST/ALT or CK) >10% above normal

36 (8.8%) were symptomatic when tests were drawn. Of 40 patients who had additional evaluation, only 2 had treatment changes (both symptomatic)

Expert Opinion Drug Saf 2011 (Nov 1)

What is the Yield of Testing Transaminases?

Retrospective review of a primary care practice 1014 of 1194 patients on a statin had a

monitoring test done in a 1 year period 10 of 1014 patients (1%) had a significant

transaminase elevation, and 5 (0.5%) had a moderate transaminase elevation, but none were due to the statin

Arch Intern Med 2003;163():688-92

A 60 yo man with Type 2 DM presents for evaluation. He has a strong family history of colon cancer . His other problems include CRI and hypertension. Most recent HBA1C was 7.4, He has been managing his diabetes with diet. Most recent Cr 1.8 (CrCl 49). What do you recommend for this patient?

A) Metformin B) Glypizide C) Glyburide D) Glargine

Reduced Risk of Colorectal Cancer With Metformin in Patients With Type 2 DM

Meta-analysis of 4 studies, with 107,961 diabetic patients

Metformin treatment was associated with a significantly lower risk of colorectal cancer (RR .63, CI .47-.84, p=.002)

Diabetes Care 2011; 34: 2323-2328

Metformin Package Insert

Lactic acidosis risk of 0.03 cases/ 1000, with a fatality rate of 0.015/1000

Discontinuation if Cr >1.5 in men and >1.4 in women, and advises against initiation in people > 80 years of age unless they have a normal creatinine clearance

Other contraindications include congestive heart failure requiring medical management, acute or chronic metabolic acidosis, and acute presentations of dehydration, hypotension, and sepsis

Cochrane Review

206 studies 47,800 person-year of exposure to metformin,

and 38,200 patient-years in the non-metformin comparison group

no cases of fatal or non-fatal lactic acidosis in either group

96% of studies allowed for at least one high risk group to be included

Cochrane Database Syst. Rev.; 2005 Jul 20;(3)

Incidence of Lactic Acidosis in Metformin Users (1)

Patients with a metformin prescription from 1980-1995 in Saskatchewan Health administrative database.

11,797 patients with 22,296 person years of exposure. Two patients had a hospital diagnosis for lactic acidosis (rate 9 /100,000)

Rate of lactic acidosis in diabetic patients not on metformin 9.7/100,000 (2).

1. Diabetes Care 1999 Jun: 22(6) 925-7 2. Diabetes Care 1998; 21:1659-1663

Rational Recommendations for Metformin Use

eGFR Action >60 No contraindications

<60 and > 45 Continue use, check Cr every 3-6 months<45 and >30 Use lower dose (1/2 dose) Check Cr every 3 months Do not start new patients

<30 Stop Metformin

Diabetes Care 2011;34: 1431-1437

Does Metformin Improve Outcomes in Patients With Type 2 DM and CHF ?

12,272 new users or oral diabetes agens between 1991-1996 reviewed. 1,833 had CHF

Of these patients treated for DM with CHF, 208 received metformin monotherapy, 773 were given sulfonylurea monotherapy and 852 received combination therapy.

Fewer deaths occurred in patients receiving metformin monotherapy (52% receiving sulfonylurea’s died, 33% receiving metformin monotherapy died, 31% receiving combination therapy died)

Diabetes Care 2005; 28: 2345-2351.

Primary Care Urology

A 84 yo man presents with hematuria. He had an episode last week, but has had hematuria for the past 4 days. He has had some hesitancy , frequency and nocturia for several years. Meds: ASA, MVI, omeprazole. A urinalysis is done which just shows RBC’s, no WBC’s. Cystoscopy shows no bladder malignancy. CT scan of the abdomen shows no renal lesions.

What do you recommend to help stop future hematuria?

A) Tamsulosin

B) Weekly dose of norfloxacin

C) Finasteride

D) Pyridium

E) Stop his aspirin

Finasteride Treatment of Hematuria in Patients with BPH

Meta-analysis of multiple small studies for using finasteride for treatment of BPH associated hematuria

Use of finasteride resulted in decreased hematuria (OR .11, 95% CI: .06-.21, p<.05) over 12 months

Zhonghua Nan Ke Xua. 2006; 16 (8):726-729.

How Finasteride Works to Decrease Hematuria

Randomized 30 patients to receive finasteride 5 mg vs placebo for 4 weeks prior to planned prostetectomy.

The suburethral and hyperplastic prostate specimens were examined for microvessel density (MVD).

MVD was the same in the hyperplastic areas for both, but was statistically lower in the suburethral area in patients taking finasteride ( 9.08 vs 13.94, p<.05)

Urol Int 2008; 80 (2): 177-80.

What is Finasteride Good for?

Symptoms of BPH- marginal Decreasing risk of acute urinary

obstruction BPH related hematuria