2. A Case of a 55-year-old Male with Uncontrolled
Hypertension and Diabetes
ExpertPanel
Dr. J.N.Srinivasulu (Nephrologist)
Dr. Vamsi (Endocrinologist)
Dr. Ganesh (Cardiologist)
Dr. Pavan (Cardiologist)
Moderator:Dr
. Goutham (General Physician)
3. Patient Presentation and History
3
A 55-year-old male presents to the clinic for a routine follow-up visit. He has a
sedentary lifestyle (post-Covid-19, working from home as a programme coder), is
an occasional smoker, and has a known history of hypertension and type 2
diabetes mellitus (T2DM). The patient reported fatigue, severe headache, and
difficulty maintaining an erection.
4. Concerns and complaints
4
● Fatigue
● Occasional headache
● Difficulty maintaining an erection
History of Illness
Patient started experiencing symptoms of fatigue last year after being treated for
Covid-19, but the symptoms gradually improved over 6 months and now have
re-appeared over the last 2 months .
He complains of dull, throbbing headache mostly in the morning ,once every 4-5days for
the last 15days with pain radiating from the frontal area and radiating backwards.
Also he complains of not being able to maintain an erection during sexual activity
although being sexual aroused. This has developed gradually and is affecting his married
life since the past 4 months. He has history for sudden awakening at night.
5. Medical and Surgical History
5
Hypertension: Diagnosed five years ago
T2DM:Diagnosed 3years ago
Dyslipidemia: Diagnosed 6years ago
Appendectomy: 20 years ago
Allergies:
None
6. Current Medication
6
Glimepiride 1mg +Metformin 500 MG OD
T
elmisartan 40 mg
Atorvastatin 10 mg OD
Patient had also admitted that sometimes he doesnʼt take medicines.
7. Family History
7
Father: Died of myocardial infarction at 60
Mother: Alive, hypertensive, diabetic
Siblings: one brother (hypertensive), one sister (diabetic)
8. Physical Examinations
8
GENERALEXAMINATION
Ht:165 cm;Wt:80 kg;
BMI:29.4 kg/m2 (obese)
Pulse: 84/min, regular
Respiration: 14/min, shallow
Blood pressure:190/100 mmHg
T
emperature:98.4˚F
O2 saturation: 98%on room air
The patient is afebrile;no cyanosis, pallor, icterus,
edema.
SYSTEMICEXAMINATION
CVS:S1 and S2 heard, no murmurs or rubs,
sinus rhythm
RS:Air entry equal on both sides, no
rhonchi or crackles
PA:Mild hepatomegaly present
CNS: Conscious, oriented, no neuro deficit
11. Additional Investigations might include 1/2
11
General Screening
Complete Blood Count (CBC): To assess for anaemia,
infection, or other haematological disorders that might
contributeto fatigue and headaches.
Evaluationofprimarydisease
Glycaemic status
a.Hemoglobin A1c (HbA1c): T
o assess the patient's
glycemic control over the past 3 months and evaluate
the effectiveness of antidiabetic therapy.
b. Glucose profile
c. BP
Evaluation of ComorbidConditions
Metabolic
ComprehensiveMetabolic Panel (CMP): T
o evaluate
electrolytes, kidney function, liver function, and
blood glucose levels, which can help identify any
abnormalities related to hypertension, diabetes,
and stage 1CKD.
12. Additional Investigations might include 2 /2
12
Thyroid Function T
ests (TFT
s):T
o rule out
hypothyroidism, which can cause fatigue and
contributeto erectile dysfunction.
Serum Testosterone: To evaluate the patient's
testosterone levels, which can contribute to
erectile dysfunction if low.
Serum Prolactin: Torule out hyperprolactinemia,
which can cause erectile dysfunction and fatigue.
Evaluation for ObstructiveSleep Apnea
Evaluationof Complications
● Urinalysis and Urine Albumin-to-Creatinine Ratio
(ACR): To assess kidney function, evaluate the
presence of albuminuria, and monitor the
progression of CKD.
● KFT
● LFT
● Doppler USGof renal arteries
Evaluationof CardiacFunction
Electrocardiogram (ECG): To assess for any cardiac
abnormalities, such as left ventricular hypertrophy or
arrhythmias, which could be related to the patient's
hypertension or family history thus contributing to his
symptoms.
Echo
16. Nephrologists perspectives 1/3
16
➔ Uncontrolled Hypertension and T2DM: These are both significant risk factors for the
development of chronic kidney disease (CKD).Poor control over a prolonged period can
lead to progressive kidney damage. Inthis case, the patient's Hemoglobin A1c (HbA1c)
level of 8.2%indicates poor glucose control over the previous 2to 3months.
➔ Creatinine and Blood Urea Nitrogen (BUN): Both of these values are slightly elevated,
which could suggest a decrease in kidney function. The creatinine level is particularly
important in this context, as it is used to estimate the glomerular filtration rate (GFR), a
key indicator of kidney function.
➔ Hemoglobin and Hematocrit: These values are below the normal range, which could
suggestanemia. Anemia is common in CKD, as the kidneys play a key role in the
production of red blood cells by releasing the hormone erythropoietin.
17. Nephrologists perspectives 2/3
17
➔ Urine Albumin-to-Creatinine Ratio (ACR): microalbuminuria suggests kidney damage likely due
to the patient's uncontrolled hypertension and T2DM.
➔ The priority would be to gain control over the patient's blood pressure and blood glucose levels,
as these are modifiable risk factors for kidney disease.
➔ From a nephrologist's perspective, further testing and monitoring may be necessary to better
assess the patient's kidney function and overall health. Some of the tests and evaluations that
could be considered include:
● RepeatUrine Albumin-to-Creatinine Ratio (ACR)
● 24-hoururine collectionforprotein-a more accurate measure of protein excretion and
helps assess the extent of kidney damage.
18. Nephrologists perspectives 3/3
18
Thetestsandevaluations thatcouldbeconsidered include:
● EstimatedGlomerularFiltration Rate(eGFR):This is calculated using the patient's age, sex, race, and serum
creatinine levels. Regular monitoring of eGFR helps track kidney function over time and guides the treatment
plan.
● Serumelectrolyte levels:Monitoring potassium, calcium, and phosphate levels can help detect potential
imbalances that may be associated with CKD.
● IntactParathyroid Hormone (iPTH)level:As kidney function declines, iPTH levels may vary,
contributing to mineral and bone disorders in CKD patients.
● Evaluation for anemia: Further testing, such as serum iron, total iron-binding capacity (TIBC),ferritin, vitamin
B12,and folic acid levels, may help determine the cause of the patient's anemia and guide treatment
● Renalimaging: Renal ultrasound or other imaging studies can help assess kidney size, shape, and rule out
potential structural abnormalities or obstruction.
● Kidneybiopsy:Insome cases, a kidney biopsy may be necessary to determine the exact cause and severity of
kidney damage, especially if there's a concern about rapidly progressing kidney disease or an atypical
presentation.
● Cardiovascular assessment: People with CKD are at higher risk for cardiovascular disease.
21. Cardiologists Perspective 1/2
21
This patient presentswith multiple risk factors for cardiovascular disease.
UncontrolledHypertension is a major risk factor for many cardiovascular conditions, such as stroke,heart
failure, and coronary artery disease. Hypertension can also cause left ventricular hypertrophy, as seen in the
patient's ECGresults.
Cardiovascular risk assessment:Given the presence of left ventricular hypertrophy, increased QRSvoltage,and
uncontrolled hypertension, a comprehensive cardiovascular risk assessment to be done.
Chronic hyperglycemiacan lead to a host of complications, including diabetic nephropathy, retinopathy, and
peripheral neuropathy,and it also increases the risk of cardiovascular disease.
Anemiain patients with cardiovascular disease can exacerbate symptoms and is associated with a poorer
prognosis.
The slightly elevated creatinine and BUN levels along with an elevated urine albumin-to-creatinine ratio suggest
the presence of early kidneydysfunction.
22. Cardiologists Perspective 2/2
22
Overall, the patient's uncontrolled hypertension and uncontrolled T2DM,along with the
accompanying laboratory findings, indicate a high risk for cardiovascular
complications. It is essential to implement a comprehensive treatment plan that
includes lifestyle modifications, antihypertensive medications, antidiabetic
medications, and regular monitoring of blood pressure, blood glucose levels, and
cardiovascular risk factors.
Collaborative management involving a multidisciplinary team, including a cardiologist,
endocrinologist, nephrologist and primary care physician, would be beneficial in
optimizing the patient's cardiovascular health and reducing the risk of future
complications.
23. Diet and Lifestyle Modification
23
Dietary modification: DASHdiet
Exercise: 150 minutes/week of moderate-intensity aerobic activity
Weight loss: T
arget 5-10%body weight reduction
Smoking cessation and alcohol moderation
Continuous Glucose Monitoring, Ambulatory BP monitoring (Encourage the pt to take
control of his health by maintaining a regular calendar)
24. Optimisation of pharmacological Interventions
24
Antihypertensive:Amlodipine 10 mg daily, Telmisartan 40 mg daily
Antidiabetic: Metformin 1000 mg twice daily, Sitagliptin 100 mg daily
Lipid-lowering: Rosuvastatin 20 mg daily
For difficulty in maintaining an erection: Sildenafil 50mg may or may not be given.
Physician can educate patient that this problem can improve once, diabetes and
hypertension are controlled. Use of Sildenafil require proper evaluation and caution.
25. Addition of Amlodipine to Telmisartan 1/2
25
● Before selecting an antihypertensive agent, it is essential to consider the patient's
medical history, comorbidities, potential side effects, and contraindications.
● Reaching a normal BP goal is the most important, a choice of potent antihypertensives
are required in this patient.
● Amlodipine is a potent antihypertensive drug in the calcium channel blockers (CCBs)
class. It is particularly effective due to its long-acting and selective vasodilatory
properties, which help reduce blood pressure without causing significant reflex
tachycardia or negatively affecting the heart's contractility.
● Telmisartan works by blocking the binding of angiotensin IIto its receptor, which leads to
vasodilation and reduction in the secretion of aldosterone. This results in decreased
blood volume and a reduction in blood pressure.
● Amlodipine and Telmisartan are two different classes of antihypertensive medications,
and their combination can have a synergistic effect on blood pressure control.
26. Addition of Amlodipine to Telmisartan 2 /2
26
● Patients with diabetes: Amlodipine has been shown to have neutral or beneficial effects
on insulin sensitivity and glucose metabolism, making it a suitable choice for
hypertensive patients with diabetes.
● Patients with chronic kidney disease: Amlodipine can be safely used in patients with
chronic kidney disease, as it does not require dose adjustments based on kidney function
and has minimal nephrotoxic effects.
● Astudy published in the "Journal of Hypertension" in 2014found that the combination of
amlodipine and telmisartan provided better 24-hour blood pressure control than either
drug alone.
● Ameta-analysis of 13 studies involving 4243 patients, published in "The Journal of Clinical
Hypertension" in 2011, demonstrated that the combination of amlodipine and
telmisartan was more effective than monotherapy with either drug in reducing systolic
and diastolic blood pressure.
27. Sitagliptin and Metformin 1/3
27
The combination of sitagliptin and metformin may be an appropriate drug of choice for
this middle-aged patient with hypertension, diabetes, stage 1 renal disease, and
dyslipidemia due to the following reasons:
● Dual mechanism of action: Metformin, a biguanide, primarily works by reducing
hepatic glucose production and improving insulin sensitivity in the liver and
peripheral tissues. Sitagliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor, enhances
the effect of incretins, leading to increased insulin secretion and reduced glucagon
release. The combination of these two drugs targets different aspects of glucose
metabolism, providing better glycemic control.
28. Sitagliptin and Metformin 2/3
28
● Minimal risk of hypoglycemia: Both metformin and sitagliptin have a low risk of
causing hypoglycemia compared to other antidiabetic agents such as
sulfonylureas.
● Weight neutrality: Metformin has a weight-neutral effect or may even contribute to
modest weight loss, while sitagliptin is generally weight-neutral.
● Renal safety: Inpatients with stage 1 renal disease, sitagliptin and metformin can
be used safely without significant dose adjustments.
● Cardiovascular safety: Both sitagliptin and metformin have demonstrated
cardiovascular safety in clinical trials, which is crucial for this patient with
hypertension and dyslipidemia, as he is at higher risk for cardiovascular events.
29. Sitagliptin and Metformin 3/3
29
● Itis essential to consider the individual patient's medical history, comorbidities,
potential side effects, and contraindications before selecting antidiabetic therapy.
● The combination of sitagliptin and metformin may not be the best choice for all
patients, and other antidiabetic medications, such as sodium-glucose
co-transporter-2 (SGLT2) inhibitors or glucagon-like peptide-1 (GLP-1) receptor
agonists, may be more appropriate depending on the patient's specific needs and
circumstances.
30. Optimal Dose of Rosuvastatin 1/2
30
Rosuvastatinmay be a better choice for this patient for several reasons:
● Greater LDL cholesterol reduction: Rosuvastatin is known to be more potent than
atorvastatin in reducing LDL cholesterol levels. This may be particularly beneficial
for this patient with dyslipidemia, diabetes, and hypertension, as these conditions
put him at a higher risk of cardiovascular events. The greater LDL cholesterol
reduction with rosuvastatin may help achieve the target LDL levels more effectively
and reduce cardiovascular risk.
● Improved pleiotropic effects:Rosuvastatin has been shown to have additional
beneficial effects beyond lipid-lowering, such as anti-inflammatory and
endothelial function improvement.
31. Optimal Dose of Rosuvastatin 2 /2
31
Rosuvastatinmay be a better choice for this patient for several reasons:
● Better impact on other lipid parameters: Rosuvastatin has a more significant
impact on improving HDL cholesterol levels and reducing triglycerides than
atorvastatin.
● Lower risk of drug interactions: Rosuvastatin is metabolised primarily by the
CYP2C9 enzyme, whereas atorvastatin is metabolised by the CYP3A4enzyme. The
CYP3A4enzyme is involved in the metabolism of many drugs, making atorvastatin
more prone to drug-drug interactions. Rosuvastatin's lower risk of drug
interactions may benefit this patient, especially if he takes multiple medications
for his comorbidities.
32. Managing Difficulty in Erection 1/2
32
T
ake a proper sexual history. Evaluate
ED with SHIM questionnaire.
Sildenafil can be used to treat two specific conditions:
1. Erectile Dysfunction (ED): the inability to get or keep an erection firm enough for sexual
intercourse.
2. Pulmonary Arterial Hypertension (PAH).
Sildenafil can have serious side effects and may interact with other medications. For instance,
it should not be taken by individuals who are currently on nitrates for chest pain, as the
combination can lead to a severe drop in blood pressure.
Sildenafil should not be taken with grapefruit or grapefruit juice.
33. Managing Difficulty in Erection 2/2
33
High blood sugar levels associated with poorly controlled diabetes can cause damage to both
the nerves and the blood vessels that supply the penis, which can lead to ED.
Hypertension can cause damage to the blood vessels and impede blood flow, which is crucial
for achieving and maintaining an erection.
Effective management and control of both diabetes and hypertension could help improve
erectile function. This usually involves a combination of lifestyle modifications, such as a
healthy diet, regular exercise, cessation of smoking, reduction of alcohol intake, and stress
management, as well as appropriate medications.
While good control of these conditions can improve ED, it may not fully resolve the issue,
especially if the ED is severe or has been present for a long time. Sildenafil or tadalafil might be
required in such cases.
34. Patient Counselling
Communicationwiththepatient-trying to make him understand that his symptoms
will go away gradually as we treat the underlying metabolic conditions and help him
with lifestyle modifications to reach the target weight. Itshould involve:
3
Next
04
Ownership
03
Timing
02
● Level of urgency and explicit timing and
prioritisation of actions
● Encouraging the Patient and family to take
ownership to reach the set out targets and get
regular checkups
● What will happen next? Anticipated changes?
What is the plan? Are there contingency plans
Action
01
8
● What actions have been taken or are
required? Provide a brief rationale
35. Follow-up
35
Visit 2
Two months after the earlier
Pt reports to the clinician after three
months reporting milder symptoms of
fatigue and less frequent headaches.
Also he reported some improvement
in maintaining erection now.
(Pt. asked to report after a month but
came after almost three months)
36. Physical Examinations and Tests after 3 months
36
General examination
Ht:165 cm; Wt:75 kg;
BMI:27.5kg/m2 (obese)
Pulse: 90/min, regular
Respiration: 14/min
Blood pressure:150/85 mmHg
Temperature:98.4˚F
O2 saturation: 98%on room air
The patient is afebrile; no cyanosis, pallor,icterus,
edema.
Investigation report:-
HbA1C:7.5%
FBS 120mg/dL PPS 200mg/dL
Lipid profile:
Total cholesterol:155mg/dL
LDL cholesterol:80mg/dL
HDL cholesterol:45mg/dL
Triglycerides: 150mg/dL
37. Is this a Case of Resistant Hypertension? 1/3
37
DifferentialDiagnosisforResistantHypertension:
● Non-adherence to medication: assess the patient's adherence to the medication
regimen and address any potential barriers or challenges to adherence.
● Secondary hypertension: an underlying secondary cause like,
■ Renal artery stenosis
■ Renovascular hypertension
■ Primary aldosteronism
■ Pheochromocytoma
■ Cushing'ssyndrome
● CKD: CKD can lead to resistant hypertension due to impaired renal function and
sodium and fluid retention
38. Is this a Case of Resistant Hypertension? 2 /3
38
DifferentialDiagnosisforResistantHypertension:
● Medication Related Factors: such as nonsteroidal anti-inflammatory drugs
(NSAIDs), certain antidepressants, or hormonal therapies, can interfere with the
effectiveness of antihypertensive medications.
● Lifestyle factors: excessive salt intake, obesity, lack of physical activity, excessive
alcohol consumption, or smoking
● White coat hypertension: Ambulatory blood pressure monitoring or home blood
pressure monitoring can help determine if white coat hypertension is a
contributing factor.
● Obstructive sleep apnea (OSA):The patient has mild OSA, which can lead to
chronic hypertension due to intermittent hypoxia and sympathetic activation.
39. Is this a Case of Resistant Hypertension? 3 /3
39
Tobe diagnosed with resistant hypertension, the patient must meet the following
criteria:
The patient is taking three or more different antihypertensive medications at
optimal doses, including a diuretic.
Despite the use of these medications, the patient's blood pressure remains above
the target goal (usually defined as a systolic blood pressure of 130 mmHg or higher
and/or a diastolic blood pressure of 80 mmHg or higher).
40. Investigations for differential diagnoses of
resistant hypertension 1/3
40
Bloodtests:
a.Completeblood count (CBC)
b. Renal function tests (e.g.,serum creatinine, blood urea nitrogen)
c.Electrolytes (e.g., potassium, sodium, calcium)
d.Liver function tests
e.Thyroid function tests
f.Fastingglucose and HbA1c (to assess for diabetes)
g.Plasma renin activity and aldosteroneconcentration (to evaluate for primary aldosteronism)
h.Cortisol levels (to assess for Cushing's syndrome)
i. Catecholamines and metanephrines (to evaluate for pheochromocytoma)
41. Investigations for differential diagnoses of
resistant hypertension 2/3
41
Urinalysis:
a.Dipstick test (to check for proteinuria, hematuria, and other abnormalities)
b.24-hour urine collection for protein, creatinine clearance, and metanephrines (for suspected
pheochromocytoma)
Imagingstudies:
a.Renal ultrasound (to assess for renal artery stenosis, hydronephrosis, or other structural abnormalities)
b.Doppler ultrasonography of the renal arteries (to evaluate for renal artery stenosis)
c. CTor MRIof the abdomen (to assess for adrenal masses or other abnormalities, if indicated)
d. Echocardiogram (to evaluate left ventricular hypertrophy, cardiac function, and other cardiac abnormalities)
42. Investigations for differential diagnoses of
resistant hypertension 3/3
42
Sleepstudy:Ifnot already performed, consider a polysomnography to assess the severity of
the patient's obstructive sleep apnea and determine appropriate treatment options.
Ambulatorybloodpressuremonitoring(ABPM):This 24-hour blood pressure monitoring can
help determine if the patient has "white coat hypertension" or truly resistant hypertension.
Essential hypertension is a diagnosis of exclusion, meaning it is determined after secondary
causes have been ruled out. Itis important to continue monitoring the patient's blood pressure
and adjusting the treatment plan as needed to achieve optimal blood pressure control.
Secondary causes for uncontrolled BP is ruled out. The patient had essential
hypertension with comorbid conditions with poor adherence to therapy.
43. Review of the Prescription
43
1. Address lifestyle factors: Encouragethe patient to make lifestyle changesthat can help control blood
pressure,such as:
a. Weightloss, as the patient is obese (BMI33.7kg/m2)
b. Regular physical activity
c. Aheart-healthy diet, such as the DASH(Dietary Approaches to Stop Hypertension) diet
d. Limiting alcohol intake
e.Smoking cessation,
f.Managingstress
2. IfBP doesnʼt improve, consider addition of third antihypertensive or increasing the dose of Telmisartan to
80mg ODalong with Amlodipine 10mg OD.
