Case One: VN is a 55-year-old man with a 5-year history of type 2 diabetes
mellitus. His medical history also is significant for hypertension
and dyslipidemia. His wife has brought him to the physician's
office. She thinks that VN has been acting strangely
recently. VN agrees that he has not been feeling like himself.
Upon questioning, the doctor learns that VN does not monitor
his blood glucose levels. VN has noticed an increased frequency
of urination, fatigue, and decreased appetite. The doctor
notices that VN appears disoriented and confused. VN's vital
signs are recorded as follows: blood pressure 130/65 mm Hg
supine and 90/50 mm Hg sitting; heart rate 100 beats/min; respiratory
rate 22 breaths/min; and temperature 39ºC. His skin
turgor is poor, and his mucous membranes are dry. Significant
laboratory findings include blood urea nitrogen 55 mg/dL, serum
creatinine 3.3 mg/dL, and glucose 730 mg/dL. Other laboratory
findings are within normal limits.
According to his medical record, VN's current medications
include glipizide 10 mg twice daily, atorvastatin 10 mg daily,
hydrochlorothiazide 50 mg daily, and enteric-coated aspirin daily.
The physician suspects that VN has developed hyperosmolar
hyperglycemic state. What measures should be taken to
Case Two: PT, a 50-year-old man, presents to his doctor's office complaining
of severe toe pain. He has difficulty sleeping, walking,
or wearing a shoe. Acetaminophen has not relieved the pain.
On examination, the physician finds that the first joint of PT's
big toe is swollen, warm, erythematous, and extremely tender.
The rest of the physical examination findings and laboratory values
are within normal limits except for uric acid, which is reported
as 12 mg/dL.
The physician obtains an x-ray and synovial fluid aspirate of
the toe. The x-ray shows soft tissue swelling without evidence
of trauma or fracture. The synovial fluid shows numerous neutrophils
and intracellular monosodium urate crystals.
The physician suspects that PT has gout with hyperuricemia.
He decides to start PT on ibuprofen and colchicines. He also will
obtain a 24-hour urine collection to determine whether PT is an
overproducer or an underexcreter of uric acid. This finding will
determine whether the patient should receive treatment with
allopurinol or probenecid. The physician also wants to consider
other possible causes for PT's elevated uric acid levels.
PT's current medications are simvastatin, loratadine, and
hydrochlorothiazide. Has PT been taking any medications that
might alter his uric acid level?
Dr. Schlesselman is a clinical pharmacist based in Niantic, Conn.
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CASE ONE: VN should be treated
with insulin and oral fluids. The insulin is
necessary to reduce his glucose levels,
whereas the fluids are necessary to correct
his dehydration. During rehydration,
VN also may need potassium, sodium,
and phosphorus replacements. Although
the patient's potassium, sodium,
and phosphorus levels appear normal
before rehydration, this finding is due to
hemoconcentration and shifting of ions
due to VN's hyperosmolar and hyperglycemic
CASE TWO: Hydrochlorothiazide
use is associated with elevated uric acid
levels and precipitation of acute gouty
episodes. Thiazide diuretics are weak
acids that are secreted by the proximal
renal tubules. It is suspected that thiazide
diuretics and uric acid compete for
renal excretion. Because of this competition,
higher doses and chronic use of
hydrochlorothiazide are more likely to
inhibit excretion of uric acid.