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Hypertension and hyperlipidemia are diseases with high incidence rates and fall within the scope of chronic disease management. The rational use of drugs is particularly important. The following lists cases of wrong medication use in clinical practice in these two diseases, in order to provide reference for clinical medication use.
case 1
case data : patient, female, 32 years old
clinical diagnosis : 31 weeks of intrauterine pregnancy, hypertension during pregnancy
prescription medication: captopril 12.5mg tid
prescription problem: selection drugs are not suitable
analysis: patients with pregnancy diagnoses are clear, angiotensin converting enzyme inhibitor (ACEI)/ARB is prohibited during pregnancy, and patients with chronic hypertension with pregnancy plans should also stop taking the above drugs.
Captopril is ACEI, and the pregnancy safety of FDA for this drug is classified as C (early pregnancy) and D (middle and late pregnancy). The use of captopril in the middle and late stages of pregnancy can lead to fetal death or damage to the neonatal renal system. Excessive amniotic fluid related to anuria can lead to fetal lung dysplasia, limb contracture, bone deformity and even neonatal death.
medication recommendations: "Guidelines for Prevention and Treatment of Hypertension in China (2018)" [1] points out that the drugs that can be selected for hypertension during pregnancy include labelor , methyldopa and nifedipine . Small doses of thiazide diuretics can be considered if necessary (diuretics should be avoided in patients with reduced placental circulation). During the medication period, the pregnant woman's heart rate, blood pressure, , fetal heart rate and growth should be monitored.
case2
case data: patient, male, 77 years old
clinical diagnosis : hypertension grade 3 (extremely high risk), renal insufficiency [chronic kidney disease (CKD) stage 5, glomerular filtration rate (GFR) 13 ml/min/1.73m]
prescription content : benapril tablet 10mg qd, hydrochlorothiazide tablet 25mg qd
prescription problem : selection of drugs is not suitable.
analysis : According to the guidelines, [1, 2] is recommended. Patients with hypertension and renal insufficiency, among patients with hypertension stages 1 to 3 CKD, ACEI or ARB should be the first choice. When a single drug cannot meet the standards, a combination treatment plan based on ACEI/ARB is often used.
CKD Patients with stage 3 to 4 should use ACEI or ARB with caution. It is recommended to reduce the initial dose by half, closely monitor the levels of blood potassium and serum creatinine and , and adjust the dose and type of drug in a timely manner.
ACEI or ARB is not routinely recommended for patients with hypertension in CKD stage 4 to 5. Thiazide diuretics can be selected for mild and moderate renal insufficiency, but severe renal function should be avoided.
Hydrochlorothiazide diuretics mainly act as epithelial cells in the distal duct cavity. When renal insufficiency is incomplete, the glomerular filtration rate is significantly reduced, resulting in a greatly reduced amount of drugs reaching the site of action and is unable to play a corresponding role. Therefore, the antihypertensive drugs selected by the patient are not suitable.
medication recommendation : This patient is in stage 5 CKD, and it is recommended to use calcium channel blocker (CCB) combined with loop diuretics (furosemide) or CCB combined with α and β receptor antagonists. If necessary, other antihypertensive drugs, such as central antihypertensive drugs. CCB can be applied to patients with CKD with hypertension at different times, and its kidney protection ability mainly depends on its antihypertensive effect. Loop diuretics (such as furosemide) are recommended for patients with stage 4 to 5. β-blockers can fight the excessive activation of in sympathetic nervous system and exert antihypertensive effects. α and β-blockers have good advantages and play a cardiorenal protective role and can be used for antihypertensive treatment of CKD at different times.
case 3
case data : patient, male, 69 years old
clinical diagnosis : hypertension and gout
prescription content : hydrochlorothiazide tablets 25mg qd
prescription problems : drug selection is not suitable
analysis : patients with hypertension and gout do not recommend thiazide alone for antihypertensive treatment. Hydrochlorothiazide can affect the excretion of uric acid in renal tubules, thereby causing hyperuricemia.
medication recommendations : "Guidelines for Diagnosis and Treatment of Hyperuricemia and Gout in China (2019)"[3] Patients with hypertension and gout will be given priority to using losartan and calcium channel blockers that have both lowering uric acid (such as amlodipine , sinidipine , etc.). Potassium-expressing diuretics, beta-blockers, ACEI and non-losartan ARB all significantly increase the risk of gout.
case4
case information : patient, female, 68 years old
clinical diagnosis : hypertension (grade 2)
prescription medication : Valsartan hydrochlorothiazide tablets 80mg/12.5mg qd, benapril tablets 10mg qd
prescription problems: combination medication is not suitable
analysis : Valsartan hydrochlorothiazide tablets contain valsartan 80mg, valsartan is an ARB antihypertensive drug. Benapril is an ACEI antihypertensive drug. Both ACEI and ARB are renin-angiotensin-aldosterone system (RAAS) inhibitors. Several large studies have shown that the combination of the two treatments (i.e. ONTARGET ALTITUDE VANEPHRON-D) has no benefit and can increase adverse reactions such as worsening renal function, hyperkalemia , symptomatic hypotension and cancer risk. ACEI and ARB combination is not routinely recommended in terms of effectiveness and safety.
medication recommendations: recommends stop benapril or replace it with other types of antihypertensive drugs based on the patient's blood pressure control situation.
case 5
case data : patient, male, 67 years old
clinical diagnosis : hypertension, 2 diabetes
prescription content : metoprolol tartarate tablets 25mg bid, hydrochlorothiazide tablets 25mg bid
prescription problems : selection of drugs is not suitable.
analysis : The patient has hypertension and hyperglycemia . It is not recommended to combine β receptor antagonist with thiazide diuretics , because the combination of the two may affect glycolipid metabolism or electrolyte balance, and increase the risk of new diabetes in people susceptible to diabetes .
medication recommendations : Hypertension and hyperglycemia are considered first. If you need a combination of medication, diuretics or dihydropyridine CCB should be added based on ACEI/ARB.
case 6
case data : patient, male, 69 years old
clinical diagnosis : hyperlipidemia, hypertension
prescription content : amlodipine 5mg qd, simvastatin 40mg qd.
Prescription problem : Combination medication is not suitable
Analysis : Amlodipine and simvastatin are both substrates of cytochrome P4503A4 enzyme (CYP3A4). When combined medication, the two will compete for the same metabolic pathway. When amlodipine is combined with simvastatin with a dose of more than 20 mg/d, the blood concentration of simvastatin will increase, resulting in an increase in adverse reactions.
drug recommendations : When statin must be used in conjunction with CYP3A4 inhibitors, inducers or substrates, drugs that do not pass P4503A4 enzyme should be preferred, such as fluvastatin , pravastatin, rosuvastatin and pitavastatin , to reduce the occurrence of drug interactions. lovastatin , simvastatin, and atorvastatin need to be metabolized by P4503A4, and it is not recommended to use it together.
case7
case data: patient, male, 69 years old
clinical diagnosis : mixed hyperlipidemia
prescription content : Geffibezil 0.3g bid, simvastatin 20mg qn.
Prescription problem : Combination medication is not suitable.
analysis : the metabolic pathways of statins and fibrates are similar. At present, studies show that the possibility of hepatotoxicity and myotoxicity in the combination of gefilbezil and statins is increased, and the probability of acute renal failure is also increased. Moreover, compared with other statins, the risk of rhabdomyolysis is higher when combined with simvastatin and gefilbezil, so it is not recommended to use the two together.
medication recommendations: is better for combined hyperlipidemia, statin and fibrate drugs to lower lipids, but the combination of these two types of drugs may lead to the superposition of this adverse reaction. At present, the most research has been conducted on the combination of fenofibrate and statins among fibrate drugs, the most sufficient evidence, and the risk of adverse reactions is relatively low.
If combined, fenofibrate should be given in the morning and statins should be given in the evening to reduce interactions at peak doses. Both drugs should start from a small dose, gradually increase the dose, and check liver function and serum creatine kinase (CK). If symptoms such as myalgia occur, stop the medication in time.
case 8
case data : patient, male, 69 years old
clinical diagnosis : hyperlipidemia and renal insufficiency (GFR 25ml/min/1.73m), gout
prescription content : rosuvastatin calcium 5mg qd
prescription problem : selected drugs are not suitable.
analysis : Rosuvastatin is contraindicated in patients with GFR <30ml/min/1.73m.>
medication recommendation : It is recommended to use atorvastatin calcium. This drug and its metabolite are mainly cleared by the liver or bile. People with renal insufficiency have little impact on the excretion of atorvastatin, and patients with renal insufficiency do not need to adjust the dose. In addition, this patient was combined with gout, and atorvastatin calcium reduced blood uric acid levels by promoting renal uric acid excretion [3]. Therefore, it is recommended that atorvastatin calcium be preferred.
case 9
case data : patient, male, 69 years old
clinical diagnosis : hyperlipidemia
prescription content : atorvastatin calcium 80mg qd
prescription problems : Usage dosage is not suitable
analysis : lipid-lowering strength of statins is related to dosage. However, all statins have a "additional 6 principle" [4], that is, doubling the dose, and the lipid-lowering intensity of statins only increases by about 6%. If you double the risk of adverse reactions increases significantly, and large doses of statins are generally not recommended. Atorvastatin 80mg is currently inexperienced in my country and must be used with caution!
medication recommendations : For patients who do not meet the cholesterol levels alone using the statin drug alone, a combination of ezemeb and medium- and low-dose statin can be selected. The two have a synergistic effect in the mechanism of cholesterol-lowering. When combined, they can significantly enhance the cholesterol-lowering effect, and the safety and tolerance of the combination drug are comparable to that of statin monotherapy. Therefore, it is recommended that this patient take atorvastatin calcium 20mg qd + ezemab 10mg qd.
References:
1. Revision Committee of China's Hypertension Prevention and Control Guidelines. China's Hypertension Prevention and Control Guidelines (Revised Edition in 2018)[J]. Chinese Journal of Cardiovascular, 2019, 24(1): 24-56.
2. Chinese Guidelines for the Management of Hypertension in the Elderly in the Elderly in 2019[J]. Chinese Journal of Geriatric Disease Research, 2019, 6(2):1-27.
3. Endocrinology Branch of the Chinese Medical Association. Guidelines for the diagnosis and treatment of hyperuricemia and gout in China (2019). Journal of Endocrinology and Metabolism, 2020, 036(001):1-13.
4. Zhu Junren, Gao Runlin, Zhao Shui et al. Guidelines for the prevention and treatment of adult dyslipidemia in China (revised in 2016)[J]. Journal of Circulation, 2016, 31(10):937-953.
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Source of this article: Medical Cardiovascular Channel
Author of this article: Shi Chunhuan
Review of this article: Zhao Jiehui
Editor in charge: Peng Jianping Dai Dai
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