Family Medicine Counseling (Additional topics)
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1 Family Medicine Counseling (Additional topics) Doa'a Samarah Al Zoubi Hope/2010 batch 1. ACEI 2. Diabetic with microalbuminuria 3. Osteoporosis 4. Anti-thyroid drugs and ablation.
2 1. ACEI counseling: - Make sure that there are no contraindications: 1) Pregnancy 2) Bilateral renal artery stenosis - This is a commonly used antihypertensive drug, and it has a lot of advantages; it is considered as cardioprotective, it protects the kidneys, dilate the peripheral blood vessels and reduce the blood pressure. - It has some side effects: 1) First dose hypotensive: you should take the first tablet at night before sleep as it may cause hypotension. if you suffered from attacks of hypotension later on, then it is preferable to take it always at night before sleep. 2) Dry cough (dose-independent): you may suffer from dry cough that is continuous and not related to flu or common cold. If you it was intolerable, we may change the drug to another type "ARBs" reducing the dose of ACEI will not improve this side effect "as it is doseindependent" 3) Angioedema: if you suffer from swellings then you have to consult your doctor immediately. 4) Skin rash 5) Taste disturbances 6) Hyperkalemia and neutropenia (dysregulation in body salts) - The effects need from 1 month to 6 weeks to be apperant. - After 2 weeks, you have to come back to do some tests; KFT: ACEI may cause Hyperkalemia (side effect) Bilateral renal artery stenosis >> the first sign is deterioration in KFT. - Drug-drug interactions >> nothing "it is safe drug" بيحس ن الزالل - It is protective from microalbuminuria - ACEI should not be given with spironolactones alone (unless we give the patients diuretics) >> both drugs increase potassium levels "Hyperkalemia".
3 2. Diabetic patient with microalbuminuria: In order to suppose that the microalbuminuria is caused by diabetes, you have to: 1) Take history, do physical examination and investigations in order to exclude other causes of microalbuminuria "other than diabetes": - Exercise within 24 hrs - Infection - CHF - Marked hypertension - Athlete - Fever - Marked hyperglycemia All these may elevate urinary albumin excretion over baseline values. Do culture for UTI. 2) Get 2 of 3 specimens collected over 3-6 months period being abnormal. Management: A) Control: 1- Tight control of BP 2- Tight control of blood sugar 3- Tight control of lipids? B) Non-pregnant patient: use either ACEI (e.g. enalapril) or ARBs (e.g. valsartan) Type 1 DM ACEI Type 2 DM ACEI or ARBs C) Reduction of protein intake may improve measures of renal function (urine albumin excretion rate, GFR) - To gm/kg/day for diabetic patients who have early stages of CKD. - To 0.8 gm/kg/day in late stages. Note: if a diabetic patient is already on 5 mg ACEI, and he has microalbuminuria, then what to do? give maximum dose (24mg). Note: microalbuminuria is usually reversible if the ptient is complient to the drugs. Note: ACEI inhibitors may elevate creatinine levels "one of the kidney functions", nevertheless they have the best outcome in reducing the progression of the chronic kidney disease.
4 Osteoporosis For a female > 65 Do DEXA sscan For postmenopausal woman younger than 65 Risk assessment History: - Age - Gender - Multiparity - Smoking and alcohol >> ask it in this way "you don't smoke or drink alcohol, right?" - Diet, "does your food contains milk, cheese.. " - Caffeine, "how many times a day?", Soft drinks - Sedentary lifestyle, Immobilization (housework is not considered as physical exercise) - Past-obstetric and Gynecology History: Number of pregnancies Regularity of menstrual cycle, irregular cycles increase the risk OCP Surgeries in the ovaries, uterus and breast - Past surgical history - Past medical history: History of fractures due to minor traumas RA DM Hyperthyroidism Renal diseases Hypothyroidism (if the patient on thyroxine) - Drugs: Steroids Thyroxine Heparine Phenytoin Furosemide PPI?? - Family History of osteoporosis (age?), fracture due to minor trauma in any first degree relative. - Physical examination: BMI < 18.5
5 Anti-thyroid drugs & ablation: Antithyroid drugs: Contraindicated in breast feeding. 1) Control thyroid hormone levels in the blood 2) Need 1-2 months to work 3) Used for months 4) You should have monthly visit for follow up 5) Major side effects: - Hypersensitivity rash in 5% of cases (dermatitis) - Agranulocytosis in 0.2% >> as soon as you feel any rise in your body temperature "fever" then you should stop the medication and consult your doctor. If the patient comes with fever, then you should do septic workup, and careful history and examination to recognize the source of infection. 6) Outcome: 50% of patients will have complete remission, while the other 50% will not respond very well to the drugs. Radioactive ablation (I 131 ) - Very effective - Used in patients > 20 years - Contraindicated in: Subacute thyroiditis Pregnancy Breast feeding Childhood Active graves ophthalmopathy - Destructs the thyroid tissue - One dose results in 75% cure rate, if it was not enough then a second dose is given 12 weeks later and results in improvement of further 20%, and multiple doses may be needed to treat the remaining 5 %. - Low-cost, no need for admission - Side effects: Hypothyroidism: occurs in 10% of the patients in the first year, then accumulative risk of 5% per year. The patient becomes thyroxine dependent. 0% risk of cancer Should not contact with pregnant or immunocompromised - Patients with toxic multinodular goiter usually need more doses of radiation, but they have better prognosis and less likely to develop hypothyroidism.
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