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Tamargo J, Caballero R, Delpón E. Sex-related differences in the pharmacological treatment of heart failure. Pharmacol Ther 2021; 229:107891. [PMID: 33992681 DOI: 10.1016/j.pharmthera.2021.107891] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 04/23/2021] [Accepted: 05/03/2021] [Indexed: 12/21/2022]
Abstract
Heart failure (HF) represents a leading cause of morbidity and mortality. However, HF trials highlighted many differences between men and women with HF. Thus, women represent approximately a quarter of people with HF with reduced ejection fraction (HFrEF), while they account for over half of those with HF with preserved EF (HFpEF). There are also sex-related differences (SRDs) in the pharmacokinetics, pharmacodynamics and safety profile of some guideline-recommended drugs for the treatment of HF. As compared with men, women with HFrEF are less often treated with guideline-recommended HF drugs, experience more frequent and severe adverse reactions when these drugs are prescribed at the same doses in both sexes, and recent evidence suggests that women might need lower doses than men, bringing into question which are the optimal doses of HF drugs in women and men separately. However, information on SRDs in drug efficacy and safety in patients with HFrEF is very limited due to the underrepresentation of women and the lack of sex-specific evaluations of drug efficacy and safety in HF clinical trials. As a consequence, current clinical guidelines do not provide sex-specific recommendations, even when significant differences exist, at least, in drug safety. The aim of this article is to review the SRDs in the pharmacokinetics, efficacy and safety of guideline-recommended HF drugs and to identify emerging areas of research to improve our understanding of the SRDs, because a better understanding of these differences is the first step to achieve a personalized treatment of HF in women and men.
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Affiliation(s)
- Juan Tamargo
- Department of Pharmacology, School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón, CIBERCV, 28040 Madrid, Spain.
| | - Ricardo Caballero
- Department of Pharmacology, School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón, CIBERCV, 28040 Madrid, Spain
| | - Eva Delpón
- Department of Pharmacology, School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón, CIBERCV, 28040 Madrid, Spain
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Tamargo J, Rosano G, Walther T, Duarte J, Niessner A, Kaski JC, Ceconi C, Drexel H, Kjeldsen K, Savarese G, Torp-Pedersen C, Atar D, Lewis BS, Agewall S. Gender differences in the effects of cardiovascular drugs. EUROPEAN HEART JOURNAL - CARDIOVASCULAR PHARMACOTHERAPY 2017; 3:163-182. [DOI: 10.1093/ehjcvp/pvw042] [Citation(s) in RCA: 184] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Abstract
With longer life expectancy, as well as better survival rates after myocardial infarction, the population of elderly patients with congestive heart failure steadily increases. Large, randomized, placebo-controlled studies have shown significant beneficial effects for several classes of drugs (angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, β-blockers, aldosterone antagonists) in patients with congestive heart failure. In most of these studies, however, elderly patients were either excluded or represented only a minority of the study population. Therefore, the treatment benefit for the large population of patients aged 65 and older is still not very well documented. In this paper, we critically review the current literature with regard to outcome of heart failure therapy in this particular subpopulation.
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Affiliation(s)
- Peter C Burger
- Clinic of Cardiology, University Hospital, Basel, Switzerland
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Thiazide-associated hyponatremia in the elderly: what the clinician needs to know. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2016; 13:175-82. [PMID: 27168745 PMCID: PMC4854958 DOI: 10.11909/j.issn.1671-5411.2016.02.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Thiazide-induced hyponatremia is one of the main causes of decreased sodium levels in elderly individuals. This review presents the current evidence regarding the thiazide-associated hyponatremia. Thiazide-associated hyponatremia is observed mainly in patients with certain risk factors such as those receiving large doses of thiazides, having much comorbidity, such as heart failure, liver disease or malignancy, and taking several medications, such as non-steroidal anti-inflammatory drugs, selective serotonin re-uptake inhibitors or tricyclic antidepressants. Sodium concentration should be monitored in patients with risk factors for developing thiazide-associated hyponatremia and clinicians should measure promptly serum sodium levels in patients with neurologic signs indicating reduced sodium levels. The clinical and biochemical profile of patients with thiazide-associated hyponatremia may be that of extracellular volume depletion or the syndrome of inappropriate antidiuretic hormone secretion (SIADH). The investigation of possible thiazide-associated hyponatremia includes the exclusion of other causes of decreased sodium levels and the identification of the characteristics of hyponatremia due to thiazides (extracellular volume depletion-related or SIADH-like). Treatment should be carefully monitored to avoid serious neurologic complications due to overcorrection. Clinicians should discourage prescribing thiazides in patients with a history of diuretic-associated hyponatremia and should prefer low doses of thiazides in patients with risk factors for developing thiazide-associated hyponatremia.
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Abstract
Electrolyte and acid–base abnormalities are a frequent and potentially dangerous complication in subjects with congestive heart failure. This may be due either to the pathophysiological alterations present in the heart failure state leading to neurohumoral activation (stimulation of the renin–angiotensin–aldosterone system, sympathoadrenergic stimulation), or to the adverse events of therapy with diuretics, cardiac glycosides, and ACE inhibitors. Subjects with heart failure may show hyponatremia, magnesium, and potassium deficiencies; the latter two play a pivotal role in the development of cardiac arrhythmias. The early identification of these alterations and the knowledge of the pathophysiological mechanisms are very useful for the management of these patients.
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DiNicolantonio JJ, Bhutani J, Lavie CJ, O'Keefe JH. Evidence-based diuretics: focus on chlorthalidone and indapamide. Future Cardiol 2015; 11:203-17. [PMID: 25760879 DOI: 10.2217/fca.14.83] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Thiazide and thiazide-like diuretics are cornerstone treatments for hypertension. However, unlike chlorthalidone (CTD) and indapamide (IDP), hydrochlorothiazide (HCTZ) lacks evidence for reducing morbidity and mortality as monotherapy compared with placebo or control. Despite this fact, HCTZ is prescribed much more frequently than CTD or IDP. We believe that all hypertension guidelines should follow the National Institute for Health and Excellence (NICE) and make IDP and CTD first choice 'thiazide-like diuretics.' This article will focus on the available evidence pertaining to HCTZ versus CTD and IDP. We will review the pharmacological differences between these three diuretics, as well as the clinical trial data and important side effects.
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Barber J, McKeever TM, McDowell SE, Clayton JA, Ferner RE, Gordon RD, Stowasser M, O'Shaughnessy KM, Hall IP, Glover M. A systematic review and meta-analysis of thiazide-induced hyponatraemia: time to reconsider electrolyte monitoring regimens after thiazide initiation? Br J Clin Pharmacol 2015; 79:566-77. [PMID: 25139696 PMCID: PMC4386942 DOI: 10.1111/bcp.12499] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 08/13/2014] [Indexed: 12/13/2022] Open
Abstract
AIMS Hyponatraemia is one of the major adverse effects of thiazide and thiazide-like diuretics and the leading cause of drug-induced hyponatraemia requiring hospital admission. We sought to review and analyze all published cases of this important condition. METHODS Ovid Medline, Embase, Web of Science and PubMed electronic databases were searched to identify all relevant articles published before October 2013. A proportions meta-analysis was undertaken. RESULTS One hundred and two articles were identified of which 49 were single patient case reports. Meta-analysis showed that mean age was 75 (95% CI 73, 77) years, 79% were women (95% CI 74, 82) and mean body mass index was 25 (95% CI 20, 30) kg m(-2) . Presentation with thiazide-induced hyponatraemia occurred a mean of 19 (95% CI 8, 30) days after starting treatment, with mean trough serum sodium concentration of 116 (95% CI 113, 120) mm and serum potassium of 3.3 (95% CI 3.0, 3.5) mm. Mean urinary sodium concentration was 64 mm (95% CI 47, 81). The most frequently reported drugs were hydrochlorothiazide, indapamide and bendroflumethiazide. CONCLUSIONS Patients with thiazide-induced hyponatraemia were characterized by advanced age, female gender, inappropriate saliuresis and mild hypokalaemia. Low BMI was not found to be a significant risk factor, despite previous suggestions. The time from thiazide initiation to presentation with hyponatraemia suggests that the recommended practice of performing a single investigation of serum biochemistry 7-14 days after thiazide initiation may be insufficient or suboptimal. Further larger and more systematic studies of thiazide-induced hyponatraemia are required.
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Affiliation(s)
- Jennifer Barber
- Division of Therapeutics and Molecular Medicine, University of NottinghamNottingham, NG7 2UH, UK
| | - Tricia M McKeever
- Division of Epidemiology and Public Health, University of NottinghamNottingham, NG5 1PB, UK
| | - Sarah E McDowell
- West Midlands Centre for Adverse Drug Reactions, City HospitalBirmingham, B18 7QH, UK
| | - Jennifer A Clayton
- Department of Diabetes and Endocrinology, Nottingham University Hospitals NHS TrustNottingham, NG7 2UH, UK
| | - Robin E Ferner
- West Midlands Centre for Adverse Drug Reactions, City HospitalBirmingham, B18 7QH, UK
| | - Richard D Gordon
- Endocrine Hypertension Research Centre, University of Queensland School of MedicineBrisbane, Australia
| | - Michael Stowasser
- Endocrine Hypertension Research Centre, University of Queensland School of MedicineBrisbane, Australia
| | - Kevin M O'Shaughnessy
- Clinical Pharmacology Unit, Department of Medicine, University of CambridgeCambridge, CB2 2QQ, UK
| | - Ian P Hall
- Division of Therapeutics and Molecular Medicine, University of NottinghamNottingham, NG7 2UH, UK
| | - Mark Glover
- Division of Therapeutics and Molecular Medicine, University of NottinghamNottingham, NG7 2UH, UK
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Schlitzkus LL, Melin AA, Johanning JM, Schenarts PJ. Perioperative management of elderly patients. Surg Clin North Am 2015; 95:391-415. [PMID: 25814114 DOI: 10.1016/j.suc.2014.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The older population only represents 13.7% of the US population but has grown by 21% since 2002. The centenarian population is growing at a faster rate than the total US population. This unprecedented growth has significantly increased surgical demand. The establishment of quality and performance improvement data has allowed researchers to focus attention on the older patient population, resulting in an exponential increase in studies. Although there is still much work to be done in this field, overlying themes regarding the perioperative management of elderly patients are presented in this article based on a thorough literature review.
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Affiliation(s)
- Lisa L Schlitzkus
- Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA
| | - Alyson A Melin
- Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA
| | - Jason M Johanning
- Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA
| | - Paul J Schenarts
- Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA.
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Lu G, Yan Q, Huang Y, Zhong Y, Shi P. Prevention and control system of hypokalemia in fast recovery after abdominal surgery. Curr Ther Res Clin Exp 2014; 74:68-73. [PMID: 24384576 PMCID: PMC3862196 DOI: 10.1016/j.curtheres.2013.02.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2013] [Indexed: 11/21/2022] Open
Abstract
Background Blood potassium levels were very important during perioperative management of patients undergoing abdominal surgery. According to various worldwide studies on the causes of hypokalemia and fast-track surgeries, prehospital hypokalemia was ignored. Objective The aim of this study to construct a prevention and control system of hypokalemia through proper clinical pathways and investigate the effects in terms of fast postoperative recovery of patients undergoing open abdominal surgery. Methods A total of 104 patients were randomized to an observation group or a control group. The prevention and control system of hypokalemia was constructed; it was composed of 3 major modules: blood potassium monitoring, etiologic intervention, and treatment of hypokalemia. In the observation group, blood was sampled at scheduled time points (the blood potassium monitoring module) and interventions involved the preadmission and pre- and postoperative periods (etiologic intervention module). In the control group, blood sampling was delayed until after admission (blood potassium monitoring module) and interventions were only performed during the pre- and postoperative periods (etiologic intervention module). In terms of blood potassium, indices regarding gastrointestinal motility and postoperative complications were compared. Results The severity of hypokalemia, postoperative defecation time, arrhythmia, fatigue syndrome, and urine retention differed statistically between the 2 groups (P < 0.05). The times to detect hypokalemia and resolve the blood condition before and after the surgery and at the first bowel sound, defecation and evacuation times differed significantly between the 2 groups (P < 0.01). Conclusions The prevention and control system of hypokalemia with the starting point being before admission was more effective and allows early prevention, detection, correction, surgery, and recovery of patients undergoing open abdominal surgeries and also could be used in other specialized nursing fields.
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Affiliation(s)
- Guanzhen Lu
- Affiliated Central Hospital of Huzhou Teachers College, Huzhou, Zhe Jiang Province, China
| | - Qiang Yan
- Affiliated Central Hospital of Huzhou Teachers College, Huzhou, Zhe Jiang Province, China
| | - Yutao Huang
- Affiliated Central Hospital of Huzhou Teachers College, Huzhou, Zhe Jiang Province, China
| | - Yan Zhong
- Affiliated Central Hospital of Huzhou Teachers College, Huzhou, Zhe Jiang Province, China
| | - Ping Shi
- Nursing Department, Huzhou Teachers College, Huzhou, Zhe Jiang Province, China
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The pathophysiology of fluid and electrolyte balance in the older adult surgical patient. Clin Nutr 2013; 33:6-13. [PMID: 24308897 DOI: 10.1016/j.clnu.2013.11.010] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 11/12/2013] [Accepted: 11/15/2013] [Indexed: 01/20/2023]
Abstract
BACKGROUND & AIMS Age-related physiological changes predispose even the healthy older adult to fluid and electrolyte abnormalities which can cause morbidity and mortality. The aim of this narrative review is to highlight key aspects of age-related pathophysiological changes that affect fluid and electrolyte balance in older adults and underpin their importance in the perioperative period. METHODS The Web of Science, MEDLINE, PubMed and Google Scholar databases were searched using key terms for relevant studies published in English on fluid balance in older adults during the 15 years preceding June 2013. Randomised controlled trials and large cohort studies were sought; other studies were used when these were not available. The bibliographies of extracted papers were also searched for relevant articles. RESULTS Older adults are susceptible to dehydration and electrolyte abnormalities, with causes ranging from physical disability restricting access to fluid intake to iatrogenic causes including polypharmacy and unmonitored diuretic usage. Renal senescence, as well as physical and mental decline, increase this susceptibility. Older adults are also predisposed to water retention and related electrolyte abnormalities, exacerbated at times of physiological stress. Positive fluid balance has been shown to be an independent risk factor for morbidity and mortality in critically ill patients with acute kidney injury. CONCLUSIONS Age-related pathophysiological changes in the handling of fluid and electrolytes make older adults undergoing surgery a high-risk group and an understanding of these changes will enable better management of fluid and electrolyte therapy in the older adult.
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Santos M, Dias V, Meireles A, Gomes C, Luz A, Mendes D, Caiado L, Carvalho H, Cabral S, Torres S. Hyponatremia--an unusual trigger of Takotsubo cardiomyopathy. Rev Port Cardiol 2012; 30:845-8. [PMID: 22030327 DOI: 10.1016/j.repc.2011.09.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Accepted: 05/10/2011] [Indexed: 11/20/2022] Open
Abstract
Takotsubo cardiomyopathy is an acute cardiac entity with clinical manifestations similar to myocardial infarction, accounting for 1-2% of acute coronary syndrome admissions. Its underlying pathophysiology is not yet well established. It is usually associated with acute physical or emotional stress, but the list of potential triggers has grown as the condition attracts the attention of the medical community. In order to diagnose the condition correctly and to gain new insights into it, we need to know its potential triggers as well as its clinical presentation and diagnostic criteria. We report a case of takotsubo cardiomyopathy triggered by hyponatremia.
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Affiliation(s)
- Mário Santos
- Serviço de Cardiologia, Hospital Santo António, Centro Hospitalar do Porto, Porto, Portugal.
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Santos M, Dias V, Meireles A, Gomes C, Luz A, Mendes D, Caiado L, Carvalho H, Cabral S, Torres S. Hyponatremia – an unusual trigger of Takotsubo cardiomyopathy. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2011. [DOI: 10.1016/j.repce.2011.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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Sarafidis PA, Georgianos PI, Lasaridis AN. Diuretics in clinical practice. Part II: electrolyte and acid-base disorders complicating diuretic therapy. Expert Opin Drug Saf 2010; 9:259-73. [PMID: 20095916 DOI: 10.1517/14740330903499257] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPORTANCE OF THE FIELD As with all potent therapeutic agents, the use of diuretic compounds has been linked with several adverse effects that may reduce quality of life and patient compliance and, in some cases, may be associated with considerable morbidity and mortality. Among the various types of adverse effects, disturbances of electrolyte and acid-base balance are perhaps the most common, and some of them are the aetiological factors of other side effects (i.e., hypokalaemia causing ventricular arrhythmias or glucose intolerance). The mechanism and site of action and, therefore, the pharmacological effects of each diuretic class largely determine the specific electrolyte or acid-base abnormalities that will accompany the use of each diuretic agent. AREAS COVERED IN THE REVIEW This article reviews the major electrolyte disturbances (hypokalaemia, hyperkalaemia, hyponatraemia, disorders of magnesium and calcium balance), as well as the acid-base abnormalities complicating the use of the various diuretic agents. WHAT THE READER WILL GAIN The reader will gain insights into the pathogenesis of the diuretic-induced electrolyte and acid-base disorders together with considerations for their prevention and treatment. TAKE HOME MESSAGE Knowledge of the pharmacologic properties of each diuretic class and appropriate monitoring of patients under diuretic treatment represent the most important strategies to prevent the development of diuretic-related adverse events and their consequences.
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Affiliation(s)
- Pantelis A Sarafidis
- Section of Nephrology and Hypertension, 1st Department of Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, St Kiriakidi 1, 54636, Thessaloniki, Greece.
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Indapamide enhances the protective action of carbamazepine, phenobarbital, and valproate against maximal electroshock-induced seizures in mice. Adv Med Sci 2010; 54:66-74. [PMID: 19366652 DOI: 10.2478/v10039-009-0004-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To determine the influence of indapamide on the protective action of numerous conventional and second-generation antiepileptic drugs (carbamazepine, lamotrigine, oxcarbazepine, phenobarbital, topiramate and valproate) in the mouse maximal electroshock seizure model. MATERIAL AND METHODS Electroconvulsions were evoked in Albino Swiss mice by a current (sine-wave, 0.2 s stimulus duration) delivered via auricular electrodes. Adverse-effect profiles with respect to motor performance, long-term memory and skeletal muscular strength were measured along with total brain antiepileptic drug concentrations. RESULTS Indapamide (up to 3 mg/kg, i.p., 120 min before the test) neither altered the threshold for maximal electroconvulsions, nor protected the animals against maximal electroshock-induced seizures in mice. Moreover, indapamide (3 mg/kg, i.p.) significantly enhanced the anticonvulsant action of carbamazepine, phenobarbital and valproate, but not that of lamotrigine, oxcarbazepine or topiramate in the maximal electroshock seizure test in mice. Indapamide (1.5 mg/kg) had no impact on the anticonvulsant action of all studied antiepileptic drugs in the maximal electroshock seizure test in mice. Estimation of total brain antiepileptic drug concentrations revealed that the observed interaction between indapamide and phenobarbital was complicated by a significant pharmacokinetic increase in total brain concentrations of phenobarbital. In contrast, indapamide had no impact on the total brain concentrations of carbamazepine and valproate in mice. CONCLUSIONS The selective potentiation of the anticonvulsant action of carbamazepine and valproate by indapamide and lack of any pharmacokinetic interactions between drugs, make the combinations of indapamide with carbamazepine or valproate of pivotal importance for epileptic patients taking these drugs together.
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Abstract
Antihypertensive pharmacologic treatment may be associated with diverse disturbances of electrolyte homeostasis. These drug-induced disorders are relatively common, typically including hyponatraemia, hypokalaemia, hyperkalaemia, hypomagnesaemia, hypophosphataemia and hypercalcaemia. Diuretics, beta-blockers, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are particularly likely to cause these complications. Recognised risk factors include high-dosage regimens (especially diuretics), old age, diabetes and impairment of renal function. Strategies to prevent these adverse drug reactions involve careful consideration of risk factors and clinical and laboratory evaluation in the course of treatment.
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Affiliation(s)
- G Liamis
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
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Hamano T, Yamamoto T, Miyamori I, Kuriyama M. [Hyponatremia with somnolence due to indapamide]. Rinsho Shinkeigaku 2008; 48:52-55. [PMID: 18386633 DOI: 10.5692/clinicalneurol.48.52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
We report here an 83-year-old woman presenting with somnolence possibly induced by indapamide. She was diagnosed as having hypertension (180/110 mmHg), and 1 mg/day of indapamide was administered starting in October, 2002. Two months later, she complained of nausea, vomiting, and appetite loss and frequently fell down. On admission, she was hypotensive (90/54 mmHg). Neurologically, she was in a somnolent state (Japan Coma Scale 2-20), and showed brisk deep tendon reflexes of both upper limbs with bilateral Chaddock signs. Laboratory examination showed severe hyponatremia (115 mEq/l) and hypokalaemia (2.8 mEq/l). On brain MR imaging, there were no remarkable abnormalities, except for multiple lacunar infarctions. After the administration of indapamide was discontinued, her consciousness level and serum electrolytes immediately returned to normal levels. After a good effect for stroke prevention was reported, indapamide was widely prescribed in combination with angiotensin-converting enzyme (ACE) inhibitors, or angiotensin II receptor blocker (ARB) among the neurologists. We should keep in mind the risk of hyponatremia and hypokalaemia occurring in patients receiving indapamide, especially elderly women.
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Affiliation(s)
- Tadanori Hamano
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui
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Abstract
An 18-year-old girl with nephrotic syndrome presented with a life-threatening respiratory failure and a severe encephalopathy, shortly after being started on furosemide. The evaluation confirmed furosemide as the sole culprit for the clinical manifestations. This case highlights an unpredictable dose-response relationship of furosemide. The pathophysiological basis, differential diagnosis and clinical implications of the observed findings are discussed.
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Affiliation(s)
- Ajay P Sharma
- Department of Pediatrics, University of Western Ontario, London, Ontario, Canada.
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18
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Abstract
Complex interactions exist amongst the various components of the neuroendocrine system in order to maintain homeostasis, energy balance and reproductive function. These components include the hypothalamus-pituitary- adrenal and -gonadal axes, the renin-angiotensin-aldosterone system, the sympathetic nervous system and the pancreatic islets. These hormones, peptides and neurotransmitters act in concert to regulate the functions of many organs, notably the liver, muscles, kidneys, thyroid, bone, adrenal glands, adipocytes, vasculature, intestinal tract and gonads, through many intermediary pathways. Endocrine and metabolic disorders can arise from imbalance amongst numerous hormonal factors. These disturbances may be due to endogenous processes, such as increased secretion of hormones from a tumour, as well as exogenous drug administration. Drugs can cause endocrine abnormalities via different mechanisms, including direct alteration of hormone production, changes in the regulation of the hormonal axis, effects on hormonal transport, binding, and signalling, as well as similar changes to counter-regulatory hormone systems. Furthermore, drugs can affect the evaluation of endocrine parameters by causing interference with diagnostic tests. Common drug-induced endocrine and metabolic disorders include disorders of carbohydrate metabolism, electrolyte and calcium abnormalities, as well as drug-induced thyroid and gonadal disorders. An understanding of the proposed mechanisms of these drug effects and their evaluation and differential diagnosis may allow for more critical interpretation of the clinical observations associated with such disorders, better prediction of drug-induced adverse effects and better choices of and rationales for treatment.
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Affiliation(s)
- Ronald C W Ma
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong, China.
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Miltiadous G, Mikhailidis DP, Elisaf M. Acid-base and electrolyte abnormalities observed in patients receiving cardiovascular drugs. J Cardiovasc Pharmacol Ther 2004; 8:267-76. [PMID: 14740076 DOI: 10.1177/107424840300800404] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Cardiovascular drugs can cause a variety of acid-base and electrolyte abnormalities that need to be considered when clinicians manage the large number of patients who receive these agents. Diuretic-induced metabolic alkalosis is the most common acid-base disorder observed and is associated with hypokalemia. Drug-induced hyperkalemia is the most important cause of increased potassium levels in everyday clinical practice. Multifactorial-origin diuretic-induced hyponatremia is mostly due to thiazides and should be carefully managed. This review focuses on the pathogenetic mechanisms as well as on the treatment of these metabolic derangements that are commonly encountered in patients who receive cardiovascular drugs.
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Affiliation(s)
- G Miltiadous
- Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece
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20
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Abstract
PURPOSE OF REVIEW The intake of water and electrolytes is inseparable from the ingestion of nutrients by normal or artificial means. Recent reports have agreed in criticizing the poor standards of practice and of training in the management of fluid and electrolyte balance, resulting in a large amount of avoidable morbidity, particularly in the elderly who are more vulnerable to fluctuations in body composition. RECENT FINDINGS Ageing is associated with impaired physiological reserve and a reduced ability to compensate for fluctuations in environmental conditions. These changes include reduced cardiac and renal reserve, making the elderly more vulnerable to changes in water and electrolyte gain or loss with a resulting increase in morbidity and mortality. The ability to cope with errors in prescriptions is correspondingly diminished. Dehydration is a common problem in nursing homes and in the community, due often to failures in detection and appropriate management. In many cases, the cause is iatrogenic due to diuretics or drugs which impair the intake of food and fluid. Salt and water overload, particularly in hospital patients, is also common and results in impaired recovery from surgery and increased perioperative mortality and morbidity. Hyponatraemia is also an important clinical problem in hospital and the community. SUMMARY Better training in the detection, prevention and management of fluid and electrolyte imbalance is needed to reduce common and serious morbidity associated with this problem to which the elderly are especially prone, owing to their diminished physiological reserves and increased comorbidity.
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Affiliation(s)
- Simon P Allison
- Section of Surgery, University Hospital, Queen's Medical Centre, Nottingham, UK
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Abstract
Sex should be considered during the selection of cardiovascular medications and dosages of cardiovascular medications. There is mounting evidence that clinically important differences between the sexes exist in the pharmacokinetic processes that determine drug concentrations and in the pharmacodynamic processes that determine physiologic responses to pharmacologic agents. Although aging also affects these processes, aging does not eliminate the sex-related differences. The major pharmacokinetic differences between the sexes, on average, are lower weight and distribution volumes in women compared with men and lower renal drug clearance in women compared with men. Sex-related differences in hepatic drug clearance are less predictable. Pharmacodynamic responses that differ between the sexes include increased adverse cardiovascular drug effects in women compared with men (torsade de pointes arrhythmias, increased risk of hemorrhagic consequences of anticoagulation or thrombolytic therapy, electrolyte abnormalities with diuretics, myopathy with HMG Co-A reductase inhibitors, cough with ACE inhibitors, and increased incidence of thrombosis). Recommendations for optimizing cardiovascular drug therapy for the older women include individualization of drug selection to minimize the number of medications and side effects; dosage adjustment based on age, size, and sex; close monitoring for side effects; and consideration of cost and access to medications. Optimal care for the older woman with cardiovascular disease will also require investigation of cardiovascular medications in older women and of therapies for cardiovascular diseases that are more common in women than men.
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Affiliation(s)
- Janice B Schwartz
- Divisions of Clinical Pharmacology and Cardiology, University of California, San Francisco and Jewish Home of San Francisco, San Francisco, CA 94112, USA.
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22
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Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2002; 11:529-44. [PMID: 12426939 DOI: 10.1002/pds.662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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23
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Howes LG. Hyponatraemia and hypokalaemia caused by indapamide. Med J Aust 2002; 177:53-4; author reply 54. [PMID: 12088485 DOI: 10.5694/j.1326-5377.2002.tb04578.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2002] [Accepted: 05/09/2002] [Indexed: 11/17/2022]
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