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Dr. Schlesselman is an assistant clinical professor at the University of Connecticut School of Pharmacy.
DM, a 45-year-old man, is a patient at the ambulatory care clinic. During this visit (his third to the clinic), the pharmacist checks his blood pressure, obtaining a reading of 155/85 mm Hg. The chart shows that he had similar readings on previous occasions.
According to the chart, he has no significant medical history and is not currently taking any medications. The pharmacist recognizes that, according to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines, DM has stage 1 hypertension. She also knows that his goal blood pressure is <140/90 mm Hg. DM admits to using additional salt on his food and eating canned food products. The pharmacist advises DM on lifestyle modifications, including reducing his sodium intake to <6 g of sodium per day.
Two months later, DM returns to the clinic for his appointment. His blood pressure reading is 158/91 mm Hg. DM admits that he did not adhere to the lifestyle modifications recommended at his last appointment. Since DM's blood pressure continues to increase, treatment will be initiated. According to JNC 7 guidelines, what is the recommended first-line treatment for DM?
TD, a 26-year-old man, presents to the retail-based clinic with a chief complaint of nasal congestion, sneezing, and nasal itching. He explains that his symptoms have lasted for 6 weeks and he "just can't take this any longer." He says that his symptoms, occurring nearly every day of the week, are so bothersome that he is unable to function at work or to sleep at night. At first, he thought he had developed a cold, but now that the symptoms have persisted for more than 1 month, he felt he should seek help.
The clinician suspects that TD has allergic rhinitis. Given that TD's symptoms have lasted for more than 4 weeks and occur more than 4 days per week, the clinician has classified TD's symptoms as persistent. She has classified his symptoms as moderate-to-severe since they impair his sleep and daily activities. The clinician cannot recall the treatment guidelines for initiating therapy for moderate-tosevere persistent allergic rhinitis, so she asks the pharmacist what would be an appropriate agent to choose for TD. What should the pharmacist recommend?
With a patient without any compelling indications, such as DM, the recommended first-line therapy is a thiazide diuretic.
For moderate-to-severe persistent allergic rhinitis, the Allergic Rhinitis and its Impact on Asthma guidelines recommend initiation of intranasal steroids. If symptoms are not improved after 2 to 4 weeks, the dose of intranasal steroid can be increased, antihistamines can be added to relieve itching or sneezing, ipratropium can be added to control rhinorrhea, or decongestants can be used to reduce nasal blockage.