Question

CASE #2 A 63 year old man with type 2 diabetes has an average BP of 151/92 over the span of several weeks of measuring at home and in the clinic. He also has albuminuria. Stage 2 Hypertension: The BP treatment goal patients with diabetes and HTN is less than 130/80. While some patients can be effectively treated with a single agent, serious consideration should be given to starting with 2 drugs of different classes, especially if BP is more than 20/10 mm Hg above their BP target. Giving both medications as a fixed dose combination may improve adherence. In this man with diabetes and HTN, any of the first-line classes of antihypertensive agents (diuretics, ACE inhibitors, ARBs, and CCBs) would be reasonable choices. Given the presence of albuminuria, an ACE inhibitor or ARB would be beneficial for slowing progression of kidney disease. However, an ACE inhibitor and ARB should not be used simultaneously due to an increase in cardiovascular and renal risk observed in clinical trials. What is the PLAN?

put N/A where necessary

Answer 1

Answer

in this scenario , the patient is having both hypertension and protienuria and type 2 dm .and his bp is also above the normal level .combined effect of dibetes and hypertension will damages kidney function and leads to albuminuria , elevated creatine in blood, peripheral edema ....

normal angiotensin aldosterone mechanism

decresed bp , decresed blood flow to kidney leads to release of renin from kidney , which will convert angiotensinogen present in blood to angiotensin 1. this is converted to angitensin 2 by the enzyme angiotensin converting enzyme(ACE inhibitors acts at this level ) angiotensin 2 acts by binding to angiotensin receptors(ARB acts by acting here) found in adrenal gland and releases aldosterone, which inturn increases sodium reabsorbtion in kidney, water retention in kidney , so that  blood volume will be increased and hence bp.

ACE inhibitors and ARB s inhibit these steps and controll hypertension

eg for ACE inhibitors -captopril , lisinopril

eg for ARB - losartan , telmisartan

if the bp level is not in a prescribed level for long term , even after taking single types of antihypertensives, then we can try fixed combination of drugs like ACE inhibitors and DIURETICS

ARB and CALCIUM CHANEL BLOCKERS (CCB)

ACE inhibitors and CCB

ARB and DIURETIC

combination therapy encourages to use lower dose of drug to reduce patients blood pressure and reduce side effects , effectively controll bp

side effects of ACEI and  ARB

dry cough , allergic symptoms, low bp , hyperkalemia, metalic taste ...

if we combine the ACEI and ARB , chances of developing side effects are high.

contraindivations of ACEI and ARB -bilatteral renal artery stenosis

pregmnanacy , lactation

previous allergy to these drugs

ACEI reduces intraglomerular pressure and restore size and charge integrity to glomerular capillay wall.

they also reduces protienuria and reduces rate of progression of renal disease in patient with diabetes and non diabetic renal diasease with protienuria

ACEI also helps to controll bloodc sugar level indirectly by increasing body's sensitivity to insulin

so this patient can be treated with ACEI and either diuretics or CCB combination, with frequent monitoring of blood pressure , protienuria , creatine level, albumin level in blood, monitor for side effects, along with life style changes like moderate excercise , reduce salt content....