CASE STUDIES
Case Study 1
Elvis is a 58-year-old man who comes to your pharmacy to get information about high blood pressure. He sees a cardiologist for high cholesterol and is urged to see a generalist to manage this and other issues.
The cardiologist recently placed him on atenolol for hypertension.
He has not started it because his blood pressure readings are always normal at home, ranging from 112-134/54-84 mmHg— his daughter, a certified nursing assistant, takes his blood pressure.
His blood pressure readings are only high when taken in his doctor’s office. “I feel nervous when I go see the cardiologist, and then my blood pressure is high,” he says. He reports that his blood pressure has been 200/100 mmHg in the cardiologist’s office, but he feels he does not need medication.
1. Does this man meet the diagnostic criterion for hypertension?
No, this is a typical case of white coat syndrome. The pharmacist should be sure to tell the patient to keep a log of his blood pressure readings that his daughter takes at home. He should record not only the blood pressure reading but also the time at which the reading was taken.
2. Would you tell him to start taking atenolol?
No. This patient should first try lifestyle modifications. Losing weight and starting an exercise routine should keep his blood pressure under control. If this patient develops hypertension, then the drug of choice to start him on would be a thiazide diuretic.
Case Study 2
Sandra is a 65-year-old woman with diabetes. Her BP has been difficult to control despite multiple medications. ACE inhibitors have been avoided because of borderline hyperkalemia.
Except for mild exertional dyspnea, she is asymptomatic, although she reports episodes of pedal edema after prolonged dependency. She has not taken her “water pills” today, because she wishes to avoid urinary frequency during her medical visit.
Her medications include hydrochlorothiazide 50 mg twice per day, propranolol 60 mg three times per day, and clonidine 0.2 mg twice per day; fluticasone 110-mcg metered dose inhaler as needed; insulin glargine 10 U at bedtime; and sliding scale regular insulin before breakfast and dinner.
1. Why is she not at her blood pressure treatment goal?
Sandra is not at her treatment goal due to noncompliance. The pharmacist should counsel the patient on the increased cardiovascular disease risk associated with uncontrolled blood pressure.
2. How would you manage her?
Her therapy is also not optimized. The
hydrochlorothiazide is at a dose that is above a clinical therapeutic dosage; 50 mg twice per day is only adding unwanted additional side effects. This dose can be cut back to 25 mg daily. A low-dose ACE inhibitor is strongly recommended for this patient, especially since she also has diabetes—ACE inhibitors have been shown to be kidney protective in patients with diabetes. Her K level should be monitored carefully to avoid any further increase. She should be instructed to avoid foods that are high in potassium, such as bananas, kiwis, and orange juice.
Propranolol is not optimal for treating her blood pressure and is inconvenient to take 3 times/ day.
Switching to a more selective beta-blocker such as Toprol XL will increase the patient’s compliance, thereby better controlling her blood pressure. For now, clonidine therapy should be discontinued, and the patient should be reassessed. Clonidine is lastline treatment for blood pressure, and the patient has many other options (including increases in dosages) that she may utilize prior to using these agents. Clonidine should not be stopped abruptly, however. A taper of the dosage should be used cautiously to avoid rebound hypertension.