Case study

TOT HPT 2019

09.07.2019
 Case 1
• 72/M/male.
• Known T2DM X 14 years. HT X 20 years
• Stay with wife, came alone.
• Wt: 70 kg
• Bp: 170/100 mmHg. PR: 45 X/min
• GM (F): 13.8 mmol/L. previous GM ranging
11.4 – 19.8mmol/L.
• No SMBG or home BP monitoring
 Current treatment:
• T. Metformin 1 gm BD
• T. Glibenclamide 10 mg BD
• T. Acabose 50 mg TDS (just started 2/12 ago)
• T. Simvastatin 10 mg ON
• T. Atenolol 50 mg daily
• T. Losartan 50 mg daily
• T. Perindopril 8 mg daily
• T. Amlodipine 10 mg daily
 Latest blood investigations:
• HbA1C: 12.2%
• BUSE: 6.9/141/5.2/102
• Se creatinine: 145umol/L (EGFR ?)
• SUA: 435 umol/L
• Tc: 5.3
• Tg: 3.1
• HDL: 0.7
• LDL: 4.2
• Urine albumin: 1+
• ECG, Fundus & foot examination: not done
 List down the problems…
• Elderly
• Long standing DM & HPT
• Uncontrolled diabetes & HPT
• CKD
• Polypharmacy
• Oral medications – not following guideline
• Incomplete TOD
 Problem list..
• Glibenclamide – to stop > 60 years old due to
risk of hypoglycemia
• Metformin - 1/2 dose when EGFR 30 -59
• Combination of Losartan & Perindopril –
contraindicated, risk of hyperkalemia
• Atenolol – masking hypo sx, bradycardia
• Statin – too low
 What further history U would like to
obtain?
• Compliance
• Diet control
• Hyper/hypo sx
• Postural hypotension sx
• Symptomatic bradycardia
• Cognitive assessment - ?Dementia
 How do you calculate eGFR?

Calculate eGFR for this patient:

• eGFR: 41.2 mL/min/1.73m2 (CKD stage 3B)

 OAD and kidney function
Mild Moderate Severe
OAD: (GFR 60 - 90 (GFR 30 - 59 (GFR <30
ml/min) ml/min) ml/min)
Metformin No dose 50% Avoid/STOP
Usual dose: 500 adjustment
mg – 1gm BD

Gliclazide No dosage adjustment necessary Contraindicated

Usual dose:
80 - 160 mg BD

Glibenclamide Use with caution Avoid

Usual dose:
5 - 10 mg BD

CPG management of CKD 2nd edition 2018

 Metformin: Adverse Event ,
contraindication and Precaution
Key points
• Not associated with hypoglycaemia
• Rare instances of lactic acidosis
• GI intolerance
• Vitamin B12 deficiency
• Avoid in acute hypoxemic states
• Contraindicated if eGFR <30 ml/min/1.73 m2.
How do you define CKD?
What is the target BP for this patient?
 DM AND HPT
•In 2016 the prevalence of hypertension in Malaysian diabetics was 76% (NDR KKM 2017).
•Pharmacological treatment should be initiated in patients with diabetes when the BP is
persistently ≥140 mmHg systolic and/or ≥90 mmHg diastolic.
•The presence of microalbuminuria or overt proteinuria should be treated even if the BP is <
140/90mmHg

Status Medications

1 DM + HPT without proteinuria ACE-I

2 DM + HPT with proteinuria ACE-I/ARB

Consider CCBs, diuretics or ß-
blockers if RAS blockers cannot be
used.

Target BP Control

1 DM + HPT < 140/80 mmHg

2 DM + HPT – young, IHD, CVA, CKD 130/80 mmHg

CPG management of HPT 5th editon 2018
• Pt c/o frequent hunger & sweating around 10-
11 am. Sx improved after taking 2 cups of
sweet coffee and a plate of rice. Sometimes sx
occur before sleep at night. PU 2-3 X/night,
normal amount, no LUTS.
• What is the problem?
• How to manage this patient?
• Possible hypoglycemia followed by
hyperglycemia
 How do U manage him now?
Pharmacological TX:
• T. Metformin 500 mg BD – EGFR 30 - 59
• T. Gliclazide MR 60 mg OM. Stop Glibenclamide
• Off Losartan, continue Perindopril (choose either ACE-I or ARB)
• Increase T. Simvastatin to 40 mg ON
• Off Atenolol – bradycardia, masking hypo sx
• Continue Amlodipine
• Off Acabose – HbA1C reduction is only 0.5%
• Do you want to start Insulin?

Non pharmacological Tx:

• Call wife /children – to help monitoring compliance, diet, hypo sx
• SMBG & Home BP monitoring
• Diet therapy
• To complete TOD screening
• Advise on Fall prevention
• How soon U want to see him (next TCA)?
• How frequent should U monitor his renal
profile? What to look for?
 Se creatinine, se K+, calculate EGFR
 When to refer to FMS or nephrologist?
 When to refer
Patients with the following conditions should be referred
to appropriate specialist including FMs for further
assessment.
• Severe HPT (>180/110mmHg)
• Suspected secondary HPT
• Resistant HPT
• Recent onset TOD
• Pregnancy
• Office HPT with additional CV risk
• Children & adults < 30 years old
Referral..
THANK YOU