Case Study Two: HTN, CKD, & Hypothyroidism

Managing Co-Morbidities in Primary Care
Primary care providers treat many patients with co-morbidities. It is important for primary care providers to utilize the most current evidence-based research and guidelines to treat and manage patients with co-morbidities in order to reduce risk factors and improve overall health. The following case study will be utilized to apply current guidelines for the treatment and management of hypertension (HTN), chronic kidney disease (CKD) and hypothyroidism including patient education, monitoring, and clinical end points.
Case Study A 45 year old African American male returns for a six month follow-up for blood pressure (BP) control. The patient complains of on-going symptoms over the past few months of dry cough, sleep disturbances, fatigue, constipation, weight gain, and dry skin. The patient denies pain, shortness of breath, edema, or sputum production. Pulse is 80 and regular, BP is 148/110, and BMI is 28. He is six feet tall and weighs 205 pounds. Labs reveal TSH of 5.2, free T4 of 0.8, free T3 1.8, Creatinine 2.1, BUN 22. Family history includes stroke, heart attack, and high cholesterol. Current medications are daily multivitamin, Lisinopril 10 mg once daily, over-the-counter (OTC) Robitussin, and OTC laxative as needed (University of Phoenix, 2014, Week Seven Case Study).
The patient can be diagnosed with uncontrolled HTN, subclinical hypothyroidism, and may have chronic kidney disease (CKD). Untreated HTN can lead to heart attack, stroke, renal failure, and death (James et al., 2013). Hypothyroidism is diagnosed in approximately five percent of adults, and many of them are considered subclinical (Ross, Cooper & Mulder, 2014). Hypothyroidism can increase cardiovascular risk factors such as hypercholesterolemia, diastolic HTN, and carotid intimal thickness (Klein, Ross, & Mulder, 2014). CKD is a serious disease that affects millions of people. Early detection and treatment can help prevent the progression to kidney failure (National Kidney Foundation, 2002).
Drug Therapies
Guidelines developed for the management of HTN by James et al., (2013) are the Joint National Commission Eight (JNC8). JNC8 recommends initiating pharmacological treatment for individuals with BP >140/90. Recommendations for the general black population, including those with diabetes, is to initiate treatment with a thiazide-type diuretic or a calcium channel blocker. However, JNC8 (2013) also indicates that anyone over eighteen years old with CKD and HTN should include an angiotensin-converting-enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) as initial therapy to improve kidney outcomes. The patient in the case study has been on Lisinopril for approximately six months, and his blood pressure remains elevated at 148/110. If the patient did not have symptoms or co-morbidities, an increase in dosage would be appropriate. Although an ACEI is an appropriate initial choice for this patient, there is evidence to support the addition of a thiazide diuretic.
Levy et al., (2002) developed the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines to manage CKD. Patients with a glomerular filtration rate (GFR) of < 60 for longer than three months can be diagnosed with CKD. The patient has an estimated GFR of 43 (NKF, 2009), which is classified as stage three. Thiazide diuretics are recommended in patients with stage 1-3 CKD in which GFR is >30 (KDOQI, 2002). If the patient does not have CKD, and the values are an acute change, further investigation is warranted. According to Kaplan, Bakris, and Forman (2013), a moderate to severe reduction in GFR and increase in serum creatinine has been observed in some patients treated with ACEI who have bilateral renal artery stenosis, nephrosclerosis, heart failure, polycystic kidney disease, or chronic kidney disease. The provider could prescribe an ARB instead of an ACEI to reduce the symptoms of dry cough associated with ACEI use. The provider could recommend Hyzaar (losartan 50mg/hydrochlorothiazide 12.5mg) by mouth once daily (Hamilton, 2014), and to discontinue the Lisinopril, Robitussin and laxatives. Hydrochlorothiazide and laxatives can decrease potassium levels in the blood and should not be taken together. The provider could recommend increasing dietary fiber to aid with constipation as a safe alternative.
Garber et al., (2012) developed guidelines to manage hypothyroidism. The most common symptoms of hypothyroidism are dry skin, fatigue, constipation, weight gain, and cold intolerance (Kiefer & Chong, 2014). Subclinical hypothyroidism is diagnosed with an increased thyroid stimulating hormone (TSH) level in the presence normal free T4 level (Kiefer & Chong, 2014). Multiple studies currently being conducted indicate treating subclinical hypothyroidism may lower the risk of atherosclerosis cardiovascular diseases (ASCVD) and heart failure (Garber et al., 2012). Since the patient is symptomatic and has risk factors for ASCVD, it is appropriate for the provider to prescribe medication for thyroid replacement. According to Garber et al., (2012), initial dosing is 1.6 mcg/kg/day. Recommendations for initial dosing in patients with coronary artery disease (CAD) is 25-50mcg/day. Doses should be increased slowly by 12.5-25 mcg in 6-8 week intervals to avoid side effects (Hamilton, 2014). The provider could prescribe levothyroxine 25 mcg taken orally once daily to ensure safe dosing since this patient has risk factors for CAD.
Vitamins and Herbal Supplements
Multivitamins are considered a safe supplement for most individuals, but have shown no evidence that use reduces disease progression. In general, people who eat a balanced diet and get regular sun exposure get the vitamins they need to maintain health. The patient is at no increased risk to continue taking a daily multivitamin. There is evidence to suggest that vitamin A and vitamin E supplementation should be avoided because it can increase the risk of mortality associated with CVD (Fletcher, Fairfield, Lipman, & Rind, 2014).
Fish oil (FO) supplements are associated with increased cardiovascular health and are considered safe. Research confirms that FO has been shown to lower triglycerides, and raise good cholesterol. According to Mozaffarian, Fletcher, & Rind (2014), FO supplementation was shown to lower BP and reduce resting heart rate. Evidence shows that FO and marine omega-3 fatty acids have been shown to reduce the progression of atherosclerosis and demonstrate an overall reduction in mortality associated with heart disease. The provider could recommend (FO) supplements of approximately 250 mg once daily (Mozaffarian, Fletcher, & Rind, 2014).
Patient Education, Monitoring and Clinical End Points
Lifestyle changes are necessary for this patient. Diet and exercise education are essential for this patient. The American Heart Association (AHA) endorses the Dietary Approaches to Stop Hypertension (DASH) diet. According to the AHA (2012), the DASH diet has been shown to be effective in all groups to reduce BP and is easy to follow. The availability of online tools provided by the AHA can be communicated to the patient for assistance with diet and activity changes.
The provider should educate the patient that levothyroxine should be taken in the morning 1-2 hours prior to food. Missed doses can be taken later in the day, but never take two doses in the same day. This patient is on a multivitamin that likely contains iron and calcium. Levothyroxine should be taken 2-3 hours apart from vitamins. An expected side effect for some patients is hair loss, but this usually returns to normal. Serious side effects the patient should report immediately are chest pain, irregular heartbeat, shortness of breath, seizures, a large weight gain or loss, vomiting, insomnia, nervousness, excessive sweating, fever, leg cramps and muscle weakness. It is important for providers to educate the patient that this medication should never be stopped suddenly and that it may take several weeks to feel better after beginning this medication (Lexicomp, 2014). Thiazide diuretics may cause hypokalemia, hypochloremic alkalosis, hypomagnesemia, and hypernatremia. Hyperkalemia can occur with ARBs with renal dysfunction, diabetes, or the additional use of potassium-sparing diuretics, potassium supplements, or potassium containing salts. Education for Hyzaar should include the most common side effects of dizziness, hypotension, and photosensitivity. The patient should be counseled to keep a blood pressure log until the next appointment to evaluate the effectiveness of the medication. The patient should be advised to avoid potassium supplements or salt substitutes, to immediately stop use with any decrease in vision or eye pain, to take precautions when in the sun, and to report hypotension to the provider ("Hyzaar: Prescribing information", 2013). The provider will need to monitor this patient by rechecking TSH level in 6 weeks. It will also be important to recheck creatinine levels and electrolyte levels to monitor kidney function and electrolyte imbalances. BP should be re-evaluated and symptoms should be readdressed. Clinical endpoints are TSH levels within a normal range, BP to be <140/90, and improvement in symptoms reported by the patient. Once TSH level are within normal range, the patient will require TSH levels every 6-12 months (Kiefer & Chong, 2014).
Conclusion
The case study presented shows application of current evidence-based guidelines in the treatment of HTN, CKD and hypothyroidism. Appropriate education, tools, and clinical endpoints must be provided ensure proper use of medications and realistic expectations of therapy. Primary care providers must be able to treat and manage co-morbidities in patients to improve the overall health of the patient and reduce risk factors for complications or progression of diseases.
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References
American Heart Association (2012). Managing blood pressure with a heart-healthy diet. Retrieved from http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/ PreventionTreatmentofHighBloodPressure/Managing-Blood-Pressure-with-a-Heart-Healthy-Diet_UCM_301879_Article.jsp
Fletcher, R., Fairfield, K., Lipman, T., & Rind, D. (2014). Vitamin supplementation in disease prevention. Retrieved from www.uptodate.com
Garber, Cobin, Gharib, Hennesey, Klein, Mechanick, . . . Woeber (2012). Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Thyroid: Official Journal Of The American Thyroid Association, 22(2), 1200-1235. doi:10.1089/thy.2012.0205
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James, P., Oparil, S., Carter, B., Cushman, W., Dennison-Himmelfarb, C., Handler, J., . . . Ortiz, E. (2013). 2014 evidence-based guideline for the management of high blood pressure in adults. Report from the panel members appointed to the eighth joint national committee (JNC 8). Retrieved from http://jama.jamanetwork.com/article.aspx?articleid=1791497
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Lexicomp (2014). Levothyroxine: Patient drug information. Retrieved from www.uptodate.com
Mozaffarian, D., Fletcher, R., & Rind, D. (2014). Fish oil and marine omega-3 fatty acids. Retrieved from www.uptodate.com
National Kidney Foundation (2009). Calculators for health care professionals. Retrieved from http://www.kidney.org/professionals/kdoqi/gfr_calculator.cfm
Ross, D., Cooper, D., & Mulder, J. (2014). Diagnosis of and screening for hypothyroidism in nonpregnant adults. Retrieved from www.uptodate.com
University of Phoenix (2014). Week seven case study. Retrieved from University of Phoenix, HCS/507-Advanced Pharmacology course website