Podcast Ep 47: Diabetes and Hypertension Patient Case
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Podcast Ep 47: Diabetes and Hypertension Patient Case

September 9, 2019

what’s going on podcasting world and
welcome to another episode of the core consult rx podcast once again we are
going to go through a patient case today but first Cole how’s life treating you
I’m doing great we’re color-coordinating we’re starting
that up yeah I’m pretty good so for the first time in the history of podcasts we
for those of you who watch the video version or watch on Instagram we have
the same color shirt on which is pretty pretty lame yeah so yeah when you think
that through from now on this has never happened before I mean they’re off
purple and light purple dark purple it’s true yeah anyways probably should still
double check so we don’t look like weirdos when I take my shirt off that
would be an easy way to remedy that one yeah well kind of know viewers probably
more awkward by the way what are they talking about
but yes so today we’re gonna go through a patient case we haven’t done one these
in a while I’m done in a while and I don’t think we’ve ever done a whole
episode just based on it either usually it’s like we just kind of we’re doing a
topic and we’re mixing a patient case in there we’re gonna take an actual patient
we’re gonna go through it some stuff we’ve touched on before but we’re
reiterating bringing in some new stuff and I think it’s important I’m excited
absolutely so we will post a copy of the case just
with some of the background information some of the labs things like that that
we’ll talk about along with a very very brief summary of so what we talked about
we’ll post that up on the website probably I don’t post a copy of it on
medium so you can use it as show notes but we will have that available after we
get the episode published and go from there yeah this is a gonna be a
relatively trial heavy podcast episode so you can put down your pins if you
don’t like writing all the names cuz it’ll be posted you’ll have the names or
I mean take notes if you want just don’t do it while you drive don’t take notes
it’s lame yeah your your branch remember all of it yeah absolutely
photographic memory people remember that it’s the only way to get through life
yeah I’m doomed so this is actually a real patient and obviously we’ve taken
away the identifying factors of this patient
but we are going to go through some of the meds that they were currently taking
and we’re gonna talk about mainly the diabetes and hypertension aspects of the
case and we won’t really go into my child’s maybe touch on the lipids didn’t
the lipids but other than that we’re gonna leave anything else kind of a loan
but this is an actual case so we’re gonna go through it step by step now the
other thing to keep in mind is that obviously because we’re about to just
devour all these changes that we would ideally make in this situation the other
thing to keep in mind is that we would not be able to do all these in one
sitting so if you’re like listening to us make some changes to the patient’s
profile obviously this would take place over the course of a few visits to get
all the set we wouldn’t be able to just stop all these meds and start new ones
that would be way too confusing and wouldn’t happen right they would be the
long-term goal and in the meantime if labs or something got in the way of them
that you might have to redirect right so we’re gonna kind of go through this but
take this as a ideal situation that would take place over a few visits but
we’re just gonna kind of walk you through what we would ideally start with
this is also an insured patient there’s limitations there but you know you know
it might be totally different with someone who’s not actually that much
different but slightly different if they did not have insurance right so to start
off basically the current medications that the patient is taking for
hypertension they are on lisinopril 40 milligrams daily hydrochlorothiazide 25
milligrams in the morning carvedilol 25 milligrams once daily it’s just a 25
milligram immediate release they are on ducks as Osen 4 milligrams and that’s it
for hypertension for diabetes they are on metformin no excuse me they are not
there on glipizide 10 milligrams and they are on Guardians 10 milligrams the
glipizide taking twice a day Jardine’s once a day and that’s it no metformin
for their lipids they are on private statin 80 milligrams once a day
and that’s gonna be all that we’re kind of discussing so we hit four for one of
one of my buddies Ryan Rosenblatt’s on Instagram saying this sounds familiar
I let him look at this when he was our clinic so yes he’s a he’s a good guy
stop Ryan all right so to go through some of the labs basically that are
pertinent for this patient hemoglobin a1c nine point six currently the GFR is
at forty eight the potassium is sitting at five point three currently that lab
was drawn a couple months ago so we would have to get a new lab if this was
a patient today we’d have to get a new med a lot of panel drawn so we could
kind of see you know what are these electrolytes are currently add but
everything else is kind of within normal limits calcium is just a tad bit high
but nothing to be alarmed and then the LDL was at 117 and triglycerides were
155 our guy that’s our guy and we’ll we’ll say for this case this
patient is let’s just say sixty six years old
sounds good to me that’s not actually his real age but close enough so what do
you want to start off with diabetes yeah I’m starved diabetes sounds good
so would you call what you kind of start things off since I’ve been blabbing on
for so yeah he’s on he’s on glipizide ten twice a day so if you’re gonna have
somebody I’m club beside you want to make sure that you’ve emphasized that
these guys need to be taking this with food and not to take it if they’re not
gonna eat because it’s really high-risk for hypoglycemia and there’s other
issues with so funny areas that I think we’ve touched on in other podcasts as
well we’re generally you would want to avoid them and less cost as an issue
because they are super cheap fortunately this guy’s insured unfortunately
metformin is pretty super cheap too so there’s there’s not much of an excuse
not to have tried metformin out you at least I’ve tried it so who knows
women have this guy’s history maybe he did tried and he just had the worst
diarrhea in the history of diarrhea and that’s why he’s not on it but ideally we
would want to we’d want to get him on metformin and potentially or if not
definitely get him off the Clippers I’m yeah and and like Cole was saying we
typically save glipizide or things like piglet his own for patients who just
cannot afford other other options metformin is free at several places
Publix I’ve noticed one I think Harris Teeter possibly maybe wall mites at
least at one March $4 list so there’s plenty of options for patients to get
metformin and then the the new American Diabetes Association guidelines have
this really nice algorithm that you can follow depending on what the patient’s
comorbidities are and so in this case if you know if the patient was a low-income
and didn’t have the funds to pay for their more expensive meds it was
uninsured then you would go from F form into either a PA glove zone or one of
the so phony areas and then go from there
this person is insured and they’re able to get any other option that’s available
so we wouldn’t use that algorithm in that case and we would go on to one that
probably reflects a patient with diabetes that also has a s CVD risk
mm-hmm we’re gonna have very specific guidelines for those patients as well
yeah and I mean just having diabetes gives them an increased risk for a CVD
also has hyperlipidemia also has CKD so he’s got some risk factors he’s also a
little bit heavy we don’t have his exact weight but his BMI is somewhere between
or it’s right around 36 between 36 and 37 so all these are risk factors
metformin would be fine to start in him so if if you were listening closely with
the labs his GFR is pretty low so 48 and in once it gets down around below 60
especially but around 45 or so you definitely want to be really dosing
drugs or checking to see if drugs need to be really dosed fortunately metformin
is fine at this dose to go ahead and get started but some of his other ones we
might need to keep a closer eye on and you know if you
look up the like the package insert alone there is some some discrepancy as
far as whether or not you should start a patient on metformin if their GFR is
below 45 now that being said they in the same exact guidelines they’ll say if a
person has been on metformin to go ahead and just continue it so you know in that
case I think you have to look at some of the other data the primary literature
that’s available there was a study for instance that was published in diabetes
care this year that looked at metformin safety in patients with the stage 3a 3b
and for chronic kidney disease and and showed some safety profiles of metformin
in those in those lower GF ours um so if you look even like at lexicomp they’ll
basically say that you can there’s evidence that shows you can start a
metformin in a patient that has a GFR of 30 to 45 you just probably want to use a
reduced goal so like maybe a thousand milligrams total per day and then if a
patient is at risk for having an acute renal injury of some type or you know
volume down or whatever then you can even start as low as 250 milligrams once
a day and then very very slowly titrate up and just monitor the patient as you
go so I don’t want the 45 the GFR of 48 to necessarily throw because a lot of
people will not start metformin because it is lower but I would personally would
say probably go ahead and start at 500 milligrams once a day I’m on to the
renal function and then work up to a thousand milligrams or 500 milligrams ER
twice a day and call it good yeah and my understanding of that was also that you
know lactic acidosis is something you hear thrown around with metformin it’s
it’s pretty pretty rare especially with metformin a lot of that comes from an
older med that was similar that did have really high rates of lactic acidosis
hasn’t really panned out with metformin not to say it’s out of the realm of
possibility but it’s it’s not something that you should be as concerned about
and so you can you know push those that kidney function a little more
at that maybe you would have also with the ER that’s something to be aware of
as far as cost goes because some places the metformin immediate release is free
but the ER isn’t so sometimes that happens but um there are reasons why you
would want to use the ER the main one being ER being extended release the main
one being if a patient’s having stomach upset which is pretty common with
metformin a lot of times what people will do is titrate slower or maybe cut
their dose back for a time or they’ll go to the ER extended release version which
has lower rates of stomach upset or they’ll you know see how the patient’s
taking it and if they’re not taking it with a considerable meal well let’s
start taking it with food that’ll help as well so we’ve touched on that in
other episodes too but I think it’s definitely good to reiterate yeah
absolutely and I mean realistically speaking in this for is when I look at
patients I kind of I mean if if person has insurance they have funding I almost
always would start with ER I don’t really see a good point I mean I haven’t
seen any good evidence personally that says that meaty release is much more
effective or anything like that so I like the ER version I definitely think
that’s something to keep in mind yeah so it only be cost would be really the only
reason you wouldn’t so they didn’t have insurance yeah absolutely so the next
step would be if this person needed a second agent on line its authority on
Jardine’s if we added metformin we’ll talk about the Jardine’s in a second but
the glipizide I would want to stop and so as a replacement to that glipizide I
would definitely want to use a GOP one GOP ones if you look at the the new 88
guidelines they say that if a person has diabetes along with an AST VD risk that
they need to be on an evidence-based second line option that cause
cardiovascular benefits and cardiovascular outcome data and so the
only two classes that have that would be GOP ones and the sglt2 inhibitors so
he’s on the nest geo t2 which we’ll come back to but I’m I’m a big fan
the GOP ones kind of as the next line agent for for these guys just because
they don’t have really good a1c lowering they also do typically are not
associated with hypoglycemia a lot of times have low side effect profile maybe
some constipation and things up at the beginning but Levin nauseam and the best
you know for patient who’s maybe not adherent or doesn’t like taking
medications they have once-weekly options that are very effective so all
that kind of being said I’m definitely usually looking as a GOP one for a
patient if they’re dealing with cardiovascular risk along with diabetes
is a second line agent and if people are if you’re dealing with a needle phobic
situation bring out your motivational interviewing usually you can convince
these guys that it’s important and the the difference between that and an
alternative is significant enough especially when you start talking about
weight loss and somebody who may be obese and as trouble with weight their
whole life they’re probably going to get a little bit from from the GOP ones as
opposed to some weight gain with other ones like so fond of ureas and they’re
much lower risk much lower risk for hypoglycemia like Mike mention versus so
funny area so if it’s covered definitely a great option and there’s almost always
one that’s covered by almost all insurances nowadays and you know that
being said GOP ones are not created equal so one of the best things about
this class of med as far as a data stamp from a status standpoint is they’ve
actually all been compared to each other for the most part so for a long time we
had Victoza once weekly liraglutide and once daily it once daily yeah sorry that
was like the market leader so we had by a de frst which was twice daily victor
Victoza came along and was actually shown to be superior as far as a1c
lowering weight loss all that good stuff in the lead trials and so it was
superior they became kind of like the gold standard for a comparison so when
by durian came out the buy it is once weekly version it was compared to
Victoza was shown to be inferior so did not meet
the criteria for non inferiority with the duration 6 trial then tans iam came
along which has been since removed from the market unfortunately for them and
that was shown to be inferior with the harmony 7 trial and then trulicity when
that one came along to do like low tide that one in there were wine sick or I’m
sorry the award sex that one showed that basically it was it met the criteria for
non inferiority with a the market leader Victoza and and I was very one see
lowering that was very one see Lauren did not meet the criteria for non
inferiority with weight loss but for a1c then you know we were good so that for a
long time was kind of the one I would always go to if they weren’t going to
use Victoza and then I was empty came around and I was empik also was compared
to instead of Vic Toews at this time I was compared to trulicity because
Victoza and it was a bigger made by the same company novo nordisk and it was
superior to trulicity in the sustain 7 trial and so the way I kind of think
about things is Victoza if you want to once once a day option and then if you
need a once-weekly go with those epic first and then if insurance won’t cover
that trulicity if insurance won’t cover that and kind of go from there right try
for a once-daily if they don’t cover that yeah you know by Darion is a big
pain in the you-know-what to inject people hate injecting it which is why
trillest ii was so it was a relief because you can’t see the needle so
that’s another big thing for people who might be afraid of needles it’s just a
little click and then bang you’re done I mean you barely feel it so it is it is a
good thing to pitch to somebody who might be totally against him and they
think it’s insulin saying it’s emphasizing that it’s non insulin it’s
pretty important too because they very frequently associated with that and you
know they had a family member or parent or an aunt who was on insulin and they
saw them injecting all the time and not to say that you should demonize insulin
because they very well may end up on that someday
and you don’t want to hurt that opportunity to you know start that but
you can say that no this isn’t insulin this is what we’re starting you on now
so you know don’t worry about that and you know the other thing is the as far
as the agents that have cardiovascular benefit most of them at this point have
studied to see if – basically they were trying to show cardiovascular safety
with the GOP ones along with the dpp-4 inhibitors sglt2 inhibitors but what
they found was there’s actually a decrease to a cardiovascular risk for an
event you know decreased mortality with some of the agents and not with others
so the three main ones that actually have good data we have Victoza with the
leader trial we have the trulicity now with rewind that was the the top-line
data was was released they’re gonna I think present the entire study next year
early next year at the conference and then OHS epic with sustained six they
showed cardiovascular benefit as well and then believe it or not tans iam
actually had benefit but they had already taken it off the market so
proportionally for them but their harmony outcomes trial came out and did
show benefit so kind of that keeps it narrowed down to two those three agents
as well trulicity Victoza knows epic so for this
person I would ideally want to start as empik unfortunately I used the formulary
app if you haven’t seen that you definitely should check it out you can
put in the person’s insurance that they have depending on which state you’re in
and whether it’s Medicare Medicaid commercial insurance government whatever
and I ran it through and checked it it was in pic was not covered but trulicity
was so for this patient I would want to do trulicity once a week especially if
he’s needle phobic they won’t actually see the needle probably won’t even feel
it and we can kind of show them how to use the device itself but metformin and
trulicity would be my two treatment options of choice I had some people I
worked with in the past you were concerned with like say you’re switching
or adding some hang on they didn’t just want to wipe
off the chiffon area because they were they like wanted to taper it I guess
they were concerned about them going hi I didn’t really share the concern do you
think we would just be able to just take it off I mean yeah we typically don’t
taper off yes it is anyway you know we’d be–we’d
ultimately you’re more worried acutely about a severe low than you are about
the blood sugar spiking a little bit so absolutely and since GOP ones are
notorious for that I mean since the finer trios are notorious for that I say
just take it off yeah for sure so let’s talk if he actually needed
three agents so his a1c was nine point six mm-hmm
he’s on jardian so you know we could always add metformin and optimize the
Jardine’s and then add trulicity if we wanted to but for just sake of the
podcast if we didn’t need to use three agents I do like guardians as an option
they that one has outcome data as far as cardiovascular benefit with the emperor
egg outcomes trial showed decrease the chance of cardiovascular events
hospitalizations from heart failure and actually chose to decrease horsing
around nephropathy so some renal protective properties
invokana also has outcome data as well with the canvas trial that one wasn’t as
impressive to me it also increases risk for amputation of the lower limb and
some of the things that i’m not a fan of with invokana so jordan’s would be the
one that i would definitely go with I would just take his dose from the ten
milligrams that he’s on and bump it up to 25 milligrams after we found out that
he was tolerating the medication and so if you’re wondering why if he wasn’t on
jardian to why we would have gone with an injectable before Guardians because
it’s oral it would kind of make sense to add that on is it’s really the adverse
effect profiles so GOP ones like you mentioned pretty low risk maybe in the
first week you might get some nausea and stuff but should go away with sglt2 is
just based on their mechanism of action with them basically peeing out glucose
you’re gonna have an increased risk for Ginetta your area infections and they’ve
also seen potentially an increased risk for fractures Mike mentioned the
invokana with the increased risk for amputations so there are some concerns
that you’d want to be aware of there also renal e dosed or leased audiences
so his GFR is getting down there so you’d want to keep an eye on it if
you’re just going based on the package insert they would say to stop it if it
went below 45 or not initiate if it’s below 45 that being said there was some
renal benefit in the trial so you know you can weigh those two things in the
trial they actually used a GFR of down to 30 right so they unfortunately was
approved before the truck this study came out so right definitely yeah small
risk of Aki as well yeah you know that’s why we would definitely go with the joke
you want before and that’s gel t 2 thing we see sometimes definitely the if I had
to pick three agents for this person and you know they didn’t want to be on
insulin because I also would be a fan of using like a basal insulin instead of
the Giardia is possibly but the patient was just absolutely unwilling to do
insulin then you know metformin trulicity Jordans for this particular
patient I think would be the way to go and so on out of dpp-4 like januvia they
have similar mechanisms of action to GOP ones they’re very safe flow adverse
effect profile but they’re pretty super wimpy and are you super and they’re
expensive so you don’t have the a1c or cardiovascular benefit that you’ve seen
with the GOP ones so at this point it’s not comparable there should hopefully be
a oral GOP one and the pipeline but dpp-4 is not so much yeah and you’re
gonna get you know roughly about a half a percentage an a1c so it like Coulson
pretty wimpy and please don’t add GOP ones and dpp-4 inhibitors together I
just have this conversation today but if you if you look at a GOP one like our
natural GOP one it’s in our system is broken down by dpp-4 that’s the kind of
the pathway so we either want to inhibit dpp-4
south in Lao our natural GOP wanted to stick around longer or we want to give a
synthetic GOP one and in the case of all these agents we have available they’re
already resistant to dpp-4 so you don’t have to give a dpp-4 inhibitor on top of
it you’re not really gonna get any added benefit probably any given worse
constipation and things like that so probably not a great option if you look
at the guidelines they don’t recommend anywhere to use those agents together so
one of the other and hopefully the one yeah and then you know above all these
agents the thing I would also recommend if it’s possible is to refer this person
to diabetes education to review lifestyle men you know management’s diet
exercise all the above so that they can because if they can change their
lifestyle then these meds will actually work to their full potential if the
person is still living this same exact lifestyle that got them to become a
diabetic in the first place probably the meds are not gonna do what
they’re supposed to yeah I mean if the three-month you know anyone see refill
checks are great but if you can get somebody who’s motivated who wants to
meet with somebody consistently whoever it is that just to
keep them motivated answer their questions about lifestyle I mean that’s
half the battle with diabetes if not more than half absolutely so anything
else with diabetes I think that’s it cool is anyone sees it six now we’re
good to go so and when I say diabetes obviously I hope it’s obvious to
everyone type dose type – yeah yeah we’re not I probably should have
specified that just in case somebody calls me out on it but yeah obviously if
this is a type one I had this type one we’re gonna switch them to all this
stuff and send my attendant yelled at me turn turns out the podcast was totally
wrong it’s completely wrong type to you people all right
hypertension let’s do it we want to start so I guess starting off with you
know lisinopril I wouldn’t mess with that at all I think that that’s a great
option first line for this patient they’re not currently spilling any
protein but definitely a good option for anti hypertensive
and it can be narrow protective in patients with diabetes as well we
wouldn’t have to start this patient in with an ACE inhibitor if they were on no
therapy at all wouldn’t have to start them on that but because they’re not
currently spilling protein but still you know definitely a good first line I were
to go wrong with it yeah hard to go wrong now you know his
potassium is creeping so we saw it was at five point three nine to hold it but
maybe something you want to keep an eye on definitely recheck that hasn’t been
checked in two months and it’s also partly potentially from the Guardians as
well yeah so yeah I can add to it all right
and so he’s on 40 once a day I guess could consider 20 twice a day right and
not a thing yeah did we have we talked about that on here before I can remember
you definitely talk about an Instagram we’ve talked about and talked to her on
Instagram but the there is a study shows that lisinopril
20 milligrams twice a day versus 40 milligrams once a day does seem to give
you a little bit better blood pressure lowering so something you could could
consider if the patient was willing to take something twice a day yeah and even
though he’s not spilling protein you know he’s got kidney issues as well so
you know any any potential for Nefer protection William would be good
absolutely so let’s talk about hydrochlorothiazide let’s talk about I’m
sure we’ve mentioned this before no have away I probably know we have the people
who use that are like AHA this again they’re probably just positive yeah so
you know we’re gonna say hydrochlorothiazide while it will lower
blood pressure it’s probably not a great option for a patient who’s already at
risk for having some sort of a cardiovascular event later in life just
because you do not get we don’t have the same outcome data that we do with our
quote unquote evidence-based thiazide diuretics so we knowing that the other
agents can potentially decrease things like you know mortality and am i
depending on which agent things like that you know we would obviously be in
favor of lowering the risk of using hydrochlorothiazide doesn’t really make
a whole lot of sense to me unless you’re just using for the sole
purpose of having it as a combination product with an ace because it is in
combination with a lot of stuff you know what I would encourage researchers to do
what’s that prove us wrong you know do some big trial with a cheat easy that
proves that it’s just as good as the other ones or better and I would be you
know how be very happy with that because it’s so super cheap but so far there is
not anything like that yeah I’d be Tuesday I could stop talking about it I
know you know they’d be like in your face and I’d be like that’s great it’s
25 cents for a hundred pills so awesome and and you know the cost thing was an
issue before but IND Apple ID which is one of the evidence based designs that
we’re gonna talk about in depth of my Dizz on the $4 list at Walmart it is
these agents are very cheap now I will say cloth Alden which I like I had a
encounter the other day where I realized it’s not as cheap as I thought so even
with them it was a patient who didn’t have insurance and he was looking
everywhere for a 90 day supply once a day and the best we could do with a good
rx coupon was 30 bucks for 90 days so I thought that one was cheaper but in DAP
amide it is on four dollar list so that one is cheaper uninsured patients
definitely goes in-depth online yeah you know there’s some of the data that backs
those up in Devon Maude has been shown to decrease mortality as well as stroke
risk in patients who were you know elderly in free-living veterans so the
high vet trial specifically patients who were eighty to a hundred years old
that’s how high you know that’s all these patients wouldn’t have a lot of
data in that they really had a friend of mine and you know in depth mind really
was effective and then also with progress when you added in depth mod to
an ACE inhibitor you decrease the chance of having a second stroke in patients
who had already had some sort of a stroke event previously or transient
ischemic attack so it definitely has some data there as well
chlorothalonil has been shown to be as effective as lisinopril or amlodipine
lowering the risk of mortality MI stroke is you know composite we saw that with
all hat it definitely has positive outcome data
in elderly patients as well we saw that with Shep and you know there’s a big men
analysis that was done in 2015 that was published in hypertension and showed
basically that in using in DAP amide instead of hydrochlorothiazide could
lower the systolic blood pressure of basically up to eight point seven if you
look at like the confidence interval could lower the systolic blood pressure
up to eight point seven millimeters of mercury more than hydrochlorothiazide
and then it was seven point three millimeters of mercury with quote a low
down so you know the with a patient like this who is I think it’s systolic was
157 depending on which goal you’re using I’m switching to some of these better
agents you know would be a good option and then if you have if you look at
actually like the hypertension the resistant hypertension guidelines they
actually say if a patient is on hydrochlorothiazide and you’re having a
hard time getting them to goal blood pressure then just switch to an
evidence-based thigh because they know that they’re more effective and see
that’s the thing I mean I see the temptation because they’re in so many
combination products it makes it it makes it really convenient for the
patient you know that there’s not going to be any issues getting it paid for
because it’s so cheap they’re really tiny so people they’re not going to
complain about taking them but ultimately it’s it’s really not even all
that great at lowering blood pressure not just the the cardiovascular risk at
marina risk and all that kind of stuff it’s not a great diet retic either you
know yeah it’s it’s funny that that that’s the one because that buys not new
it’s funny that that’s the one that just took over and everybody started using it
which you know might been before you know they were all they were all pretty
much equivocal as far as they knew they just went with a cheat easy but yeah and
a pomide we may have mentioned it at one point but it also has some calcium
channel blocker like effects which adds to its blood play blood pressure
lowering which we’ll get to a question I have later on about mixing it with some
other calcium channel blockers but um yeah yeah that’s why it’s better the
other thing to consider would be now this is you know
obviously the patient’s already on a bunch of different medications so we’re
kind of just switching at this point but let’s say the person was on just less
than a purlin we needed a second line agent we definitely could add either a
closeout owner and a pin line or we could also add something like amlodipine
you go in calcium channel blocker now it’s not an evidence-based thiazide but
ACE inhibitor plus hydrochlorothiazide was compared directly to banaz apparel
and amlodipine in the accomplished trial now I like this trial a lot however I
would like to see it done with ace inhibitor with either core thousand or
in depth and wide compared to ace inhibitor and them a little pings I feel
I could get the same exact results with both groups and that in that case but
because they use hydrochlorothiazide they did this study and it was
interesting too because at the end of the study they noticed that the blood
pressure lowering itself in this particular case was about the same so it
wasn’t statistically different however the in lutein group did decrease
the patient’s primary outcome where they’ve looked at cardiovascular death
non fatal stroke non-fatal of mine it was a significantly lower risk for
that primary composite in the group that used amlodipine instead of
hydrochlorothiazide number needed to treat was 45 and then if you kind of
break it down from there you can you can see some of the other benefits then
through the secondary outcomes when you kind of break everything apart but about
two-thirds of the patients in the study were type 2 diabetics and so you know
this definitely would apply to our patient and it gives you an idea of
maybe we’re not we don’t need to just treat numbers and lower blood pressure
like I’ll just give them any agent because as long as we get the numbers
down we’re gonna be treating them we need to make sure we’re treating
outcomes as well and you know I’m low team would be a very good option which
is you know why it’s considered one of the first the you know top line drugs to
use as well and hypertension you know that that quickly brings up an
interesting point that I’ve noticed with a lot of older trials is that they were
done versus older drugs that might not be used anymore
or release drugs that aren’t like the the highest-quality like say
comparing other old diabetes meds to glipizide or something like that where I
wonder what it would look like if you compare them to GOP ones or Jardine’s or
something like that and they’re never gonna retest stuff but you know
interesting thing and they’re also there’s gonna be some huge hesitancy to
just like we saw that the GOP ones where you had the company that makes Dorion
testing it against Victoza they put up all the money to test it to show that
their drug is not inferior and get it approved and you know yeah yeah it’s
shown to be inferior so you just basically paid money to show your drugs
wasn’t as good you basically paid for the marketing of Victoza that’s uh
that’s pretty sucky yeah so not how you want to run your definitely not how you
drug this but you know how are they gonna know you know you don’t know until
you try yeah I actually commend them for at least giving it a shot because most
of them were like no we just compared to placebo that’s fine yeah so we don’t
ever really get to see what that is but we have to kind of extrapolate from aim
from what we see individually individual trials mm-hm
so anyways there are some other little stuff you could do with the blood
pressure if you weren’t getting it to gold but if you made these switches over
a period of time then you probably would get him to go and we’ve talked about
goals before and what that would look like but there’s some other data showing
that if you dosed one of his medications at night it may produce better blood
pressure lowering maybe if you just needed to tweaked a few points one of
those being the Mae Peck trial if you’re gonna do that ideally you would do the
ACE inhibitor at night because the rass system is more active at night
I guess dosing lisinopril twice a day would kind of take care of that for you
and if you want to do the rest in the morning sure whatever you want to do
them all at night sure whatever you know but at least one is showed that that
benefit and I like separating him out too personally because and one of the
things that the may pact trial was looking at was patients who were
considered you know quote-unquote non dippers so normal circadian rhythm you
know we have a dip in our blood pressure at night while we’re resting however
there are patients that actually had there’s actually a pretty hefty
percentage of patients that their blood pressure will increase at night while
they’re sleeping and they call those non dippers and so if you can give if you’re
especially if you’re unsure if you haven’t been able to do like 24-hour
ambulatory monitoring of blood pressure you’re not really sure what category
that patient would fall into having them take like their I’m looping and thiazide
Iraq in the morning and then they let Central at night you know you’re making
it makes sense to cover for dipper and non dipper according to like you know
the kinetics of the drug itself plus you’re covering for like holes at the
Rath system being more active at night and so that’s kinda how I’d normally
think about if I have three drugs I bumped ace or ARB to nighttime and
then the other two in the morning them that’s just me and if you’re looking for
more data for that the micro hope trial also dosed ramipril at night no it’s all
more positive outcomes through that yeah my not familiar with it micro hope was
the study that we got our renal protection from an ACE inhibitor and
diabetes patients so make sure you check that out check it out so kind of going
back to this patient we’ve been talking a lot of theory
so keeping listener pearl we would want to switch the thiazide diuretic and then
if we needed another agent from there we would do the in blood of pain now
this patient is also on doxa zosyn so first of all we probably like cole
said would not need a fourth agent from here if he did Ducks assistance probably
not the best option if you remember all hat when they looked at ACE inhibitor
calcium channel blocker and thiazide diuretic which is kind of what we always
think about when we think of all hat people often forget there was a fourth
arm to that which was doctors Olson that arm was stopped early because they
noticed that patients were getting an increase a significant increase in
occurrence of heart failure and so they stopped the doxa zosyn arm and continued
on with the other three so ducks is Osen not great even if the patient had BPH
still not a great option I would use more of a
you know a specific targeted alpha blocker and those patients so tamsulosin
would be a much better option taxes Osen just not a great not a great option in
my opinion and which it’s used a lot to try to kill two birds but yeah yeah you
know it’s not really worth it it’s better day better it’s not the bird the
bird from having a stroke or am I then trying to be convenient
don’t kill the birds that’s want to keep that’s my that’s my modern witches there
is actually a study called pathway to and they compared three different fourth
line agents to see which one was kind of better for resistant hypertension and
they look at Smyrna lactone they looked at dot zosyn and looked at DISA Prabhu
so pre-law and Smyrna Lawton was the more effective agent when it comes to
reducing the blood pressure compared to the other agents so significantly better
reduction in blood pressure now this patients potassium is elevated so we
would have to use some caution there whether or not we could actually use
spur in Lawton would depend on what is potassium came back at this point to see
if it’s if it’s higher or not we may not be able to if it’s if it’s over five
then we can so as it sits right now in the old potassium reading that we have
we wouldn’t be able to use bernal at own but doctors Olson I would definitely
would try to avoid and then you know the next step would be maybe looking at a
beta blocker which she’s already on a beta blocker right which we noticed so
if you’ve you know followed our little algorithm that wouldn’t be the number
one number two even number three options for them for multiple reasons not
evidence base as far as stroke am I it does masks scientists and symptoms or
can mask signs and symptoms of hypoglycemia so in diabetics it’s not
all that great carvedilol mixed with Doc’s is I was in both centrally acting
agents probably increases risk for hypotension so yeah maybe not maybe not
all that great but if you’re if you’re looking for a fourth or fifth line and
it’s potassium is high you know you can consider carvedilol and okay so to kind
of to kind of recap you know if this particular
killer patient we were working on in clinic then lisinopril it’s good to go
it can stay hydrochlorothiazide probably would want to switch to either in depth
medical fallow down and then at the same time I would probably discontinue either
the doctors ocean or taper off the curve ADA law at that point probably for me I
would do the doxa zosyn and then the next agent I would add would be in
loaded pain and then try to taper off the curve ADA law and then after the
third visit if his blood pressure is still not controlled then look at a
fourth line agent either adding the supernal at soon if possible that in an
ideal situation or looking at possibly bringing that carvedilol back on if we
needed to you’re gonna get some really good blood pressure lowering from Smyrna
lactone yeah just be aware if he’s a couple points off I mean you could get
10 15 points from spironolactone right and I think rails the rails trial that
our failure study they should burn a lot to him being added on to standards of
care I want to say they got 19 it’s almost 20th night yeah just under 20
millimeters of mercury decrease in the systolic blood pressure so very
effective drug but yeah so that’s uh that’s kind of the blood pressure stuff
and hopefully that wasn’t too confusing to kind of cover it makes sense in our
minds it does but not always when we talk start talking about it out loud but
hyperlipidemia let’s go that real quick yeah come in for a landing with the
lipids so we did just do a review over the lip and a lip any guidelines it
wasn’t a lot of time on that it was kind of funny that I actually got a message
on Instagram about hey like literally like the two days actually put after we
posted it sounds like you should really do a I never said I’m an Olympic
eyelines I just said him back to life oh yeah that’s that’s a good idea
that’s what you are on top of it there’s your link enjoy sir so yeah this guy’s
on private ad and you know private is not a bad drug but it’s not considered a
privacy and it’s not considered a high intensity statin
this guy would be indicated for a high intensity statin based on multiple risk
factors so we probably want go with receivest at nori torva statin
it seems that a tourist at an 80 would probably be the best most studied option
to start with and it is okay to start high like that and if you’re having any
issues which hopefully don’t then potentially back off but that would
probably the way to go and with the LDL of 117 and what was his triglycerides
155 you’ll probably get those to pretty close to to goal with that switch but
there are other options if you don’t necessarily right you know the other
thing to consider in in this very well could be that you know we have to have
this conversation with them but this could be the reason for the patient not
being on a torva the risk of having muscle aches myalgias myopathy does seem
to go up with our more lipophilic statins so we would they get better
there are tissue penetrations so you have a higher chance of having those
those risks so if this patient was experiencing that like Cole saying you
can drop the dose you can even switch to like every other day there’s some data
I’ve looked at just recently I got a question about this on Instagram there’s
data than a couple of trials small trials but a couple of more they looked
at like for sue satin once a week and still had some else you got – I’ve seen
a days that way so it’s past there’s a lot of times things we can do with the
dosing – coming work around the patient having myalgias or apathy but the other
thing would be to switch to a hydrophilic statin which would be our
receiver in our prava so which could be wise on problem
exactly but you never know – we have to have that conversation ahead of time but
a tour of a tea versus prov a tea you get much better LDL lowering and since
if you check out our new lipid guideline review on our couple episodes ago you’ll
see that the lipid LDL goals are backing up their back so now the person needs to
have better control down so we would tour baby would be more ideal yeah and
the guidelines always say that they’re indicated for a high intensity statin or
maximally tolerated statin so some statin is better than no stat so
whatever you can get them on that he can tolerate that’s great and we
mentioned this in the lipid episode as well but the reduce it trial that came
out about a month ago now if you’ve got them on this maximally tolerated statin
manage triglycerides we’re still above 150 and you could consider adding on vez
epi’ which is a fish oil basically a specific type of fish oil as a Penn
devil yes that’s what it is I was gonna say and then I was like you know what I
messed it up bad enough and you had a lipid episode I’ll need the message
today I said it twice in my head before I showed my mouth I feel like I feel
good about it so uh it did show benefit cardiovascular benefit when added on to
a statin which you know they’ve been doing studies with Omega threes and
different fish oils for ever and it hasn’t really panned out so this is kind
of the first time that’s pretty cool and it was specifically don’t know if you
saw this or not but it specifically in patients who triglycerides were over 20
right which making this switch take torva ATI ticket tolerate would almost
definitely get his triglycerides below 150 right but if they didn’t because our
people who have high triglycerides in super low LDL and HDR super low LDL
super high HDL could be an option yeah and controlling his blood sugar also we
give his triglycerides down yes so that’s the other piece once you get his
a1c down he probably will not need further triglyceride coverage but just
in case that’s you know we have that option available just a cool thing to be
aware of as well as mine as well as another you know piece of the puzzle
with the new guidelines but if you haven’t seen the one with the Ziva check
out the reducer trial it was in November of England Journal of Medicine and yep
so definitely make sure you take a look at that it’s a big one but yeah and then
other than that just regular lifestyle changes and immunisations and all that
stuff he’d be due for certain – thank you
just a little PSA guys jinguk’s really is on backorder so if you want to hold
off on like pushing it really hard for like six months so we can stop getting
just absolutely mauled by people for not having it I would really appreciate it
it would be great keep pushing it maybe some key if I get
the question of when we’re gonna get Shane Grigson one more time I might have
yeah well but I’ve already gotten the first dose what’s gonna happen if I
don’t even for people who haven’t gotten their first dose in like they get angry
if they can’t get on some type of list for us to call them it even if they’re
like the four thousand the person on the list which they would be I get yelled at
mm-hmm it’s like come on guys when when I was still working like in community
pharmacy they literally a way back way back when just trying to preface this
geez you know have to be so sarcastic when when I was two and working the
community pharmacy setting the the patient literally came to me he’s like
well you probably should have made more do you think I was like oh shoot you’re
right you know learn my team of scientists well the funniest thing is
that they think it’s some conspiracy like we’re like we’re keeping it from
them and it’s like but I just dozed myself that every night right yes I keep
it all for myself because I’m not gonna have any shingles no shingles here buddy
and it’s like you know my job is to sell you this immunization so you I’m not
gonna keep it from you if the option is to give it to you but I did have an I
get the question a lot if you didn’t have chickenpox in your kit should you
so get shingles you should be born after 82 they say to
still get it because you’ve been exposed to chicken pox right they don’t ever
they don’t recommend currently the CDC the ACIP does not recommend actually
getting tested for the disaster apparently our tests are really crappy
for detecting the tiger they’re not even you know and so they that’s why they
don’t recommend it because apparently they come receiving the commercial grade
test that they use in the lab core in all those places and doctors offices and
whatnot they aren’t very good at detecting it really yeah so if you’ve
been born in 82 and in up there before then go ahead and do it so I should take
one of those doses for myself well once you hit the gun what you hit the 50 and
up which I get a strange amount of like 30 year olds asking me for it and I’m
like no not yet it’s okay but there are people
under 50 who have shingles – oh yeah I got in my pharmacy school class that had
shingles I knew a guy when I was in middle school who had shingles oh yeah I
stomach it’s gonna be a rocky rough ride the rest of his jeez I had a Verne mind
that actually got him they gave him zoster virus by accident when they were
supposed to be giving him their backs oh no after they injected they were like oh
shoot I thought that was funny get shingles every year but he’s fine yeah
he’s good to go yeah interesting
man now we got on that but the yeah so that’s our patient case I know that was
a little bit uh hopefully not too rushed but kind of going through it like I said
I’ll post the actual case with some brief summary you know that we kind of
went through today if you have any questions feel free to email us but I’ll
post it up on the website and whatnot yeah and the reason that we go through
this stuff seemingly redundantly sometimes is because it’s not only just
we know a good amount about it but this is like the most common thing in the
world yes I mean you’re just gonna see this four times five times every single
day so it’s it’s good to really nail into your brain right so make sure you
check out the actual case and and Ryan what Ryan must have missed the beginning
episode he’s now asking on Instagram when the person should follow up so this
person would be following following up every you know a couple months every
three months or so until we got everything switched the way we want it
and if we’re switching hypertension stuff I mean you might even follow up
with him a couple of weeks if you’re gonna be monitoring stuff you know and
then from there we would every couple months we would switch them things
around until we were where we wanted to be depends on the Med but yeah any
questions concerns comments we’d love to hear them make sure you email us I the
email available in the description of the episode and make sure you give us a
shout out on Instagram or whatever social media platforms you like say to
us we’ll make sure we message you back and you know if you do enjoy the podcast
we would we appreciate rating the podcast on
iTunes or subscribing on I already over Spotify wherever else you you listen to
it at it helps us out a lot as well and yeah so far so good with the ratings we
haven’t gotten we’ve had a couple like a couple of outliers couple outlier scope
but we got another for recently people were like it’s other for we hope
somebody guys doing with this fourth man yeah like someone’s like you know it’s
it’s okay but they’re rating their rating my beard they know it’s not long
ago someone if it was if it was three inches then it would be five fun yeah
yeah we have had somebody rated to so whatever it is what it is we’re better
for it yeah well but anyways all right guys thank you so much for listening we
will catch you next time and as always we really really appreciate this board
see ya you

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  1. Hey guys… just came across your channel you guys do amazing work just suscribed… heard about y'all from another pharmacy podcast I listen too.. been going thru all these videos lol… I'm a specialty pharmacist here in Florida and I like going over these videos to keep up with my non specialty meds as well. And with this new MTM side gig I'm going to be apart of its very helpful to go over non specialty meds… appreciate the content…

  2. Hello.. I wanted to add another comment to this video.. I know you guys are busy but I came across this podcast from a physician who talks about the opioid crisis a lot and I noticed he had an episode on diabetes and ketones.. very interesting podcast episode.. definitely stuff you don't hear often.. I know you guys are extremely busy but I would love to get your opinion on it…


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