Combination Of Diuretics Research Articles

Treatment patterns and adherence to antihypertensive combination therapies in Japan using a claims database

Fixed-dose combinations (FDCs) for blood pressure control can simplify prescribing, improve medication adherence, and be cost-effective. In Japan, real-world data about the class effects of antihypertensive drugs on medication adherence are limited. Using the nationwide database of medical health claims from Diagnosis Procedure Combination hospitals, treatment patterns and adherence were analyzed for 47,891 patients prescribed antihypertensive medication between April 2014 and March 2015. Adherence was assessed by the proportion of days covered (expressed as % PDC). Patients were prescribed a mean of 2.0 ± 1.0 antihypertensive drugs and 2.4 ± 1.7 pills for their index prescription. Mean adherence overall was 91.5% PDC and was inversely correlated with the number of antihypertensive drugs or pills prescribed on the index date. Mean % PDC was significantly higher (all P < 0.0001) for CCB + ARB versus ARB + thiazide diuretic combinations and for CCB + ARB + β-blocker versus CCB + ARB + thiazide diuretic combinations. Adherence was significantly higher (P < 0.0001) for FDC (CCB + ARB) versus corresponding single-drug combinations, but not for other comparisons of FDCs versus single-drug combinations. On the other hand, FDCs were not always used effectively; specifically, FDCs were frequently used concomitantly with a single agent(s) from the same drug class(es) as the FDC. From the results of our study, no clear differences were observed in medication adherence according to the presence or absence of FDC formulations, and there were cases in which FDCs were not being utilized effectively to simplify prescribing.

The relationship between death from renal insufficiency and diuretic therapy among older adults at two nursing homes catering atomic bomb survivors

In Geriatrics Gerontology International we previously reported the efficacy of reducing diuretics to prevent falls and fractures in older adults. We have since noticed another important problem, regarding the diuretic therapy for older adults with decreased muscle and water volumes. We performed a study on renal insufficiency and diuretic therapy in an attempt to confirm the need for case control study between standard diuretic therapy administered, according to guidelines and "NY-mode" diuretic therapy, which involves the administration of the mineral-corticoid receptor inhibitor spironolactone at 12.5 mg orally every other day. We reviewed the causes of death among 1,855 residents living at 2 atomic bomb survivors nursing homes, with a focus on the death certification and diuretic therapy status of 48 older adults who died due to renal insufficiency. We also evaluated the relationship between the estimated glomerular filtration rate of 407 residents using serum creatinine data and the level of independence in daily life of disabled older adults. We found that deaths due to chronic renal insufficiency were concentrated within certain period in two nursing homes examined and in patients receiving standard diuretic therapy (continuous daily loop diuretics or combination of loop diuretics with mineral-corticoid receptor inhibitor). Older adults with a relatively low level of independence in daily life showed a relatively higher estimated glomerular filtration rate, depending on their muscle volume. These results suggest the need for a case control study of standard diuretic therapy and "NY-mode" therapy among older adults with decreased muscle and water volumes to not only prevent falls and fall-related fractures but also protect the kidney from damage.

Thiazide but not loop diuretics is associated with hypomagnesaemia in the general population.

Hypomagnesaemia has been associated with various adverse outcomes. Loop and thiazide diuretics promote urinary magnesium excretion. However, it is unknown if this links to hypomagnesaemia. We study if loop or thiazide diuretic use affects serum magnesium levels and if it associates with hypomagnesaemia. In addition, we study the effect of combining a potassium-sparing diuretic with a thiazide diuretic on the presence of hypomagnesaemia. The study performed a cross-sectional analysis within 9820 participants from the prospective Rotterdam Study. Hypomagnesaemia was defined as a serum magnesium level ≤0.72mmol/L. Participants were categorized by defined daily dose (DDD), and all analyses were adjusted for age, sex, BMI, eGFR, serum potassium levels, proton pump inhibitor use, and comorbidities. Loop diuretic use was associated with higher serum magnesium levels (<1 DDD: 0.004mmol/L 95% CI: -0.008; 0.017; 1 DDD: 0.023mmol/L 95% CI: 0.013; 0.032; >1 DDD: 0.043mmol/L 95% CI: 0.028; 0.057). Thiazide diuretic use was associated with lower serum magnesium levels (<1 DDD: -0.013mmol/L 95% CI: -0.023; -0.002; ≥1 DDD: -0.018mmol/L 95% CI: -0.028; -0.010), resulting in an increased odds ratio of hypomagnesaemia of 3.14 (95% CI: 1.67; 5.92) and 2.74 (95% CI: 1.57; 4.77), respectively. These effects were predominantly seen in participants using diuretics for more than 390days. Combining thiazide diuretics with a potassium-sparing agent was not associated with lower serum magnesium levels or hypomagnesaemia. Thiazide diuretic use is associated with lower serum magnesium levels and an increased risk of hypomagnesaemia. This increased risk is not seen in participants using a combination of thiazide diuretics with a potassium-sparing agent. The use of loop diuretics is not associated with an increased risk of hypomagnesaemia.

The combination of angiotensin converting enzyme inhibitors, diuretics and non-steroidal anti-inflammatory drugs in the routine community pharmacy settings in Poland: The unrecognized problem of ‘Triple Whammy’. A pilot analysis.

Background: ‘Triple Whammy’ defined as a combination of angiotensin converting enzyme inhibitors/angiotensin receptor antagonist, diuretics and non-steroidal anti-inflammatory drugs remains an important clinical problem, particularly in patients with risk of renal impairment. Community pharmacy settings are considered to be an appropriate place for detection and solving of this drug-related problem. Objectives: To estimate the frequency of ‘Triple Whammy’ in a routine community pharmacy setting in Poland by analysis of data obtained from refilled prescriptions. Methods: We conducted anon-interventional, observational retrospective study to assess the rate of ‘Triple Whammy” cases in a community pharmacy setting in Poland. We reviewed 14243 prescriptions to find ‘Triple Whammy’ cases. The analyzed prescriptions were refilled between the 1.01.2016 and 31.05.2016 in one single community pharmacy in Poland. Results: The average age of all patients identified with ‘Triple Whammy’ was 68 (range, 56-91). We identified 12 prescriptions with ‘Triple Whammy’ among all cases, receiving most frequently ramipril (n=8 patients), diclofenac (n=6) and ketoprofen (n=5). Moreover, other medications that were prescribed to patients during the study analysis time period included proton pump inhibitors such as pantoprazole (n=3) and omeprazole (n=2), opioid analgesics – tramadol (n=1) in the fixed-dose combination with paracetamol, and one antihyperglycemic medication – metformin (n=1). Conclusions: ‘Triple Whammy’ should be considered as a potential drug-related problem in Poland. Our study suggests that geriatric population is particularly affected by this drug-related problem, and, consequently, pharmaceutical care is predominantly necessary among this cohort.

Antihypertensive Drugs in Croatia: What Changes the Drug Usage Patterns?

Purpose: Possible factors that could influence changes in patterns of prescribing antihypertensives could be identified by monitoring national trends in hypertension treatment. The choice of pharmacologic treatment in people with hypertension has important therapeutic and financial implications, due to the fact that the financial costs associated with hypertension continue to increase. The aims of our study were to identify and analyze changes in the usage of antihypertensive drugs in Croatia from 2000 to 2016 and to identify the changes in prescribing patterns as well as mean prices per defined daily dose (DDD).Methods: Data on consumption in Croatia were obtained from the International Medical Statistics database. According to the World Health Organization's Collaborating Center for Drugs Statistics Methodology, per-annum volumes of drugs are presented in DDD per 1000 population per day (DDD/1000), while data on financial expenditure are presented in euros.Findings: The consumption of drugs for cardiovascular disease in Croatia during the period from 2000 to 2016 increased 150.81%, while financial expenditure in the same period increased 47.32%. The most frequently prescribed subgroup was agents acting on the renin-angiotensin system (RAS). Their share among antihypertensives increased from 39.13% (2000) to 53.39% (2016). The share of diuretics in the same period decreased from 20.16% in 2000 to 12.73% in 2016.Implications: The prescribing patterns of antihypertensive drugs in Croatia have changed, which could be a result of a combination of different factors, such as changes in laws, pharmaceutical marketing, and guidelines on hypertension therapy. The most prescribed subgroup in all of the investigated years was agents acting on the RAS, mainly because of the increased prescribing of combinations of RAS agents plus diuretics. The financial implications of legal changes and the introduction of new generic drugs led to decreased cost per DDD of antihypertensives during the investigated period, but the total expenditure on antihypertensives in Croatia increased due to increased consumption.

Predictors for profound blood pressure response in patients undergoing renal sympathetic denervation.

Renal sympathetic denervation (RDN) as treatment for hypertension shows highly variable results. Although some patients do not show any blood pressure (BP) change and in most patients a BP reduction of at least 5 mmHg can be found, some show a reduction at least 20 mmHg. We sought to identify predictors for such a profound BP response. Profound BP response was defined as drop of at least 20 mmHg in daytime systolic ambulatory BP measurement (ABPM) 3 months after catheter-based RDN. Three different denervation devices were used for RDN, and pulse wave velocity was determined invasively in a subgroup of patients. One hundred and ninety consecutive patients were included in this analysis. Profound BP response was found in 33 patients. Patients with profound BP response were younger (P = 0.04), presented with higher baseline ABPM values (P < 0.001), were treated with ultrasound-based RDN and received more often a combined treatment with two different diuretics (P = 0.005 for both). After 3 months, a treatment target of daytime BP less than 135 mmHg could be achieved more frequently in patients with profound BP response (61 vs. 17%, P < 0.001). Age, use of ultrasound RDN, combined diuretic therapy and baseline BP independently predicted pronounced BP reduction. A second multivariate logistic regression model including pulse wave velocity if available identified baseline BP, pulse wave velocity and use of ultrasound denervation as independent predictors for profound BP response. Younger vascular age, higher baseline BP, treatment with ultrasound RDN and combined diuretic therapy were found as predictors for a pronounced BP reduction following RDN, improving BP control at follow-up.

The influence of antyhypertensive therapy of valsartan and fixed combination with hydrochlorothiazide use on pulse-wave velocity and central arterial pressure in patients with arterial hypertension of 1-2 grades in international VICTORY clinical trial

Objective - to explore influence of valsartan monotherapy use and its use in combination with hydrochlorothiazide (HCTZ) on pulse-wave velocity (PWV) and central arterial pressure (CAP) in patients with arterial hypertension (AH) of 1-2 grades in international VICTORY clinical trial. Materials and methods. The international multicenter prospective randomized clinical study VICTORY that lasted for 16 weeks included patients with 1-2 grades AH. In patients who previously received antihypertensive therapy a 7 days washout period was carried out. All patients started their therapy with 80 mg valsartan (Valsacor®, KRKA, Slovenia); in Russia the starter dose of Valsacor®, KRKA was 160 mg in previously treated patients that did not influence the study results. If after 4 weeks of treatment BP was more than 140/90 mm hg (more than 130/80 mm hg in high risk patients or in diabetes mellitus patients) the dose of valsartan was increased to 160 mg (320 mg in Russia) or diuretic in fixed combination with valsartan was added (160 mg valsartan/12.5 mg HCTZ): Valsacor® H 160 (KRKA, Slovenia). If target BP after 8 weeks of treatment was not reached valsartan dose was increased to 320 mg or fixed combination of valsartan and diuretic (160 mg/12.5 mg) was used. If target BP after 12 weeks of treatment was not reached - valsartan and diuretic 320 mg/12.5 mg were used. PWV and CAP (SphygmoCor®, AtCorMedical) were assessed at baseline and after 16 weeks of treatment. The primary endpoints were assessment of the impact of studied medications on aortic stiffness, aortic augmentation index and comparison of absolute medians of reached central and peripheral BP reduction with baseline value. Results. Of 365 patients included in the study 74 were included in PWV and CAP study subgroup. Valsartan and its combination with HCTZ were effective in CBP reduction. The mean absolute reduction of central systolic and diastolic BP after 16 weeks of treatment was 19.7±12.9 mm hg and 13.9±8.5 mm hg, respectively (р

Hypotensive Drugs and Syncope Due to Orthostatic Hypotension in Older Adults with Dementia (Syncope and Dementia Study).

To determine whether hypotensive drugs may play a pivotal role in inducing orthostatic hypotension (OH)-related syncope. Prospective, observational, multicenter study. Acute care wards, syncope units, and centers for the diagnosis of dementia. Individuals aged 65 and older with a diagnosis of dementia and 1 or more episodes of transient loss of consciousness of a suspected syncopal nature or unexplained falls during the previous 3 months MEASUREMENTS: Blood pressure was measured in the supine position and in the orthostatic position after 1 and 3 minutes. OH was defined as a decrease in systolic blood pressure of 20 mmHg or more and in diastolic blood pressure of 10 mmHg or more within 3 minutes of standing. Univariate and multivariate analyses were used to evaluate associations between hypotensive drugs and their combinations with OH-related syncope. The mean age of the study population (n=522; women, n=324) was 83.5±6.1, and the most frequent comorbidity was arterial hypertension (74.5%); 324 (67.8%) participants had had a syncopal fall and 168 (32.2%) a nonsyncopal fall. The mean number of hypotensive drugs administered (2.9±3.1) did not differ between the two groups. Syncopal falls was OH-related in 170 participants (48.0%). OH-related syncopal falls were more frequent in participants receiving nitrates (15.3% vs 9.8%, p=.06), alpha-blockers (16.5% vs 9.8%, p=.04), or combinations of angiotensin-converting enzyme inhibitors (ACE-Is) and diuretics (20.6% vs 13.0%, p=.04), alpha-blockers and diuretics (8.2% vs 3.3%, p=0.036), and ACE-Is and nitrates (8.2% vs 3.3%, p=.10). Multivariate analysis confirmed a greater risk of OH-related syncopal fall for nitrates (relative risk (RR)=1.77), combinations of ACE-Is and diuretics (RR=1.66), and combinations of ACE-Is and nitrates (RR=2.32). In older adults with dementia, OH-related syncopal falls are significantly related to treatment with nitrates, combinations of ACE-Is and diuretics, and combinations of ACE-Is and nitrates.

Can Torsemide and Combination of Loop Diuretics Improve Mortality in Patients with Chronic Heart Failure After Discharge?

The aim of this study was to investigate the effect on mortality of torsemide and a combination of loop diuretics (furosemide + torsemide) in contemporary practice in patients with chronic heart failure (HF).We investigated patients with HF in the Heart Failure Center of Fuwai Hospital from 2009 to 2013 who were discharged on furosemide, torsemide, or a combination of the 2 drugs. Using inverse probability weighting (IPW) to account for nonrandom selection of diuretic strategies, we assessed the association between different diuretic strategies and mortality.Among 956 patients, 19.7% (n = 188) received furosemide, 36.6% (n = 350) torsemide, and 43.7% (n = 418) the combination therapy. The torsemide-treated and combination-treated patients had worse heart function and higher furosemide equivalent. Univariable Cox proportional hazards models showed that the combination group had worse outcomes (all-cause HR = 2.044, P = 0.008; CV HR = 1.988, P = 0.011), while torsemide was associated with an outcome (all-cause HR = 1.640, P = 0.078; CV HR = 1.509, P = 0.147) similar to that of furosemide. After IPW, torsemide was associated with a nominally lower mortality compared with furosemide (all-cause HR = 0.738, P = 0.222; CV HR = 0.667, P = 0.110), and the association between the combination treatment and increased mortality was no longer statistically significant (all-cause HR = 1.207, P = 0.470;CV HR = 1.174, P = 0.540).We found that torsemide and the combination strategy had similar outcomes when compared with furosemide. However, considering the lack of diuretic randomized clinical trials (RCTs) conducted with the aim of exploring the effect on mortality of different diuretic treatments, prospective trials are needed to investigate the effect of different diuretic strategies in chronic HF.

EXPERIENCE WITH VALSARTAN/SACUBITRILO IN PATIENTS WITH CHRONIC KIDNEY DISEASE

Objective: The main cause of admission in patients with heart failure (HF) is congestion. Treatment is complex, because of resistance to diuretics, and limitation to the use of potassium-sparing drugs. This situation is particularly frequent in patients with heart failure and chronic kidney disease (CKD). Therefore, the use of a drug that acts simultaneously on the renin angiotensin aldosterone system (RAAS) and on the Nerprisilina, can play an important role. Objectives: To evaluate the use of valsartan/sacubitrilo in patients with congestive heart failure and kidney disease 3B-4, analyzing its impact in the improvement of symptoms as overload and the effect on renal function. Analyze the safety profile of the drug Design and method: Prospective observational study (October 2016-October 2017): 7 patients with heart failure, a depressed ejection fraction and dyspnea functional grade II/IV onwards, to which had been added Valsartan/Sacubitrilo, previous suspension of ACE inhibitors or ARA II that came taking Results: The proportion F/M was 5/2. The mean age was 71 years. All patients are hypertensive, (85.6%) diabetic, 71.4% dyslipidemic. The 71 % with Cardiomyopathy. The 57.1% was being treated with combinations of diuretics, reducing this number to the 28.6%, after adding the new drug. 3 of the 7 patients (42.9%) stopped diuretics. There were no significant changes in the glomerular filtration rate, proteinuria and arterial blood pressure. 4 of the 7 patients improved the degree of dyspnea. Only 1 of these patients went to the emergency room with symptoms of heart failure once treated with the drug. None of the patients had adverse effects which would lead to the suspension of the drug. Conclusions: Valsartan/sacubitrilo in patients with CKD is useful to improve the functional class in patients with heart failure, allowing a lower use of diuretics and reducing emergency visits for symptoms in relation to the decompensation of heart failure. It is a reliable drug and help in the therapeutic management of these patients It will be necessary to assess the impact on the long-term preservation of renal function.

NEW OPPORTUNITIES TO IMPROVE SYSTOLIC BLOOD PRESSURE CONTROL IN ELDERLY PATIENTS: FOCUS ON INDAPAMIDE SR/AMLODIPINE FIXED DOSE COMBINATION

Objective. Target blood pressure (BP) is achieved only in 1/3 of patients with arterial hypertension (HTN). The target is most difficult to achieve in elderly patients. Systolic BP (SBP) in elderly patients is the strongest prognostic factor of cardiovascular complications. Thiazide/thiazide-like diuretics and calcium antagonists are effective drugs for reducing SBP and pulse pressure (PP). They also show positive impact on aortic BP, which is associated with high arterial stiffness and is common in elderly people. The combination of a thiazide diuretic and a calcium antagonist is recommended by the current algorithms and guidelines for HTN, but due to the lack of a fixed combination, it has not yet been widely applied in clinical routine practice. Recent data on the efficacy, safety of indapamide retard and amlodipine suggest that their combination may become an alternative treatment option for HTN patients, especially in patients with high SBP and PP, in elderly patients and other groups of patients with high arterial stiffness.

COMPARATIVE ANALYSIS OF HOSPITAL PHARMACOTHERAPY OF CHRONIC HEART FAILURE WITH REDUCED LEFT VENTRICULAR EJECTION FRACTIONS IN 2009-2010 AND 2014-2015

Aim. To compare features of pharmacotherapy of patients with chronic heart (CHF) with a reduced ejection fraction of the left ventricle (LV EF) who were admitted in a specialized department of the multidisciplinary hospital in Saratov before and after the publication of the Russian National Recommendations (4 revision) on the diagnosis and treatment of CHF (2012). Material and methods . A pharmacoepidemiological retrospective study was conducted. The object of the study was the medical records of inpatients (form 003/y) with the diagnosis Heart failure (ICD-I50), that consecutively admitted to the cardiology department of the multidisciplinary hospital in Saratov from April 28, 2009 to January 19, 2010 (n=52) and from February 19, 2014 to May 20, 2015 (n=95). Patients over 18 years of age with diagnosis of CHF (NYHA II-IV) and LV EF <45% were enrolled into the analysis. For each patient, an individual registration card was filled in which the patient's clinical and demographic characteristics, prescribed medications, their daily dose, the frequency of administration, the route of administration were indicated. Pharmacoepidemiological analysis was carried out for the drugs prescribed at the 1st day of hospitalization, at the 3rd-6th day (the time of stabilization of the patient's condition, which was evaluated by the reduction in dyspnea and increase in the tolerance to physical loads). The recommendations given by the physicians at discharge of the patients from the hospital were also considered. Results . In 2014-2015 years, compared to 2009-2010 years, the number of identified arrhythmias and severe forms of arterial hypertension significantly (82.1 vs 77%; р<0.05) increased. In 2014-2015 the frequency of the prescriptions of ACE inhibitors decreased (77.8 vs 86.5%; p<0.05). The frequency of the prescriptions of angiotensin II receptor blockers, antagonists of mineralocorticoid receptors (AMCR), diuretics, oral anticoagulants, clopidogrel increased (p<0.05). In the structure of combination therapy in 2014-2015, the frequency of the prescription of the ACE inhibitor+beta-blocker and ACE inhibitor+beta-adrenoblocker+AMCR combinations decreased significantly (18.9 vs 26.9%, p<0.05 and 22.1 vs 42.3%, p<0.05, respectively). At the same time prescription frequency of the ACE inhibitor+beta-blocker+AMCR+diuretic combination increased (25.2 vs 11.5%, p<0.05). Conclusion . Pharmacotherapy of CHF in hospital in 2014-2015 is consistent with the Russian National Recommendations (4 revision) and is significantly different from the CHF therapy in 2009-2010. Keywords: pharmacoepidemiology, chronic heart failure, treatment.

Synergism of antihypertensives and cholinesterase inhibitors in Alzheimer's disease

IntroductionWe investigated the effect of antihypertensive (aHTN) medications and cholinesterase inhibitors (ChEIs) on the cognitive decline in patients with Alzheimer's disease (AD) and analyzed synergism by chemogenomics systems pharmacology mapping. MethodsWe compared the effect of aHTN drugs on Mini-Mental State Examination scores in 617 AD patients with hypertension, and studied the synergistic effects. ResultsThe combination of diuretics, calcium channel blockers, and renin-angiotensin-aldosterone system blockers showed slower cognitive decline compared with other aHTN groups (Δβ = +1.46, P < .0001). aHTN medications slow down cognitive decline in ChEI users (Δβ = +0.56, P = .006), but not in non-ChEI users (Δβ = −0.31, P = .53). DiscussionaHTN and ChEI drugs showed synergistic effects. A combination of diuretics, renin-angiotensin-aldosterone system blockers, and calcium channel blockers had the slowest cognitive decline. The chemogenomics systems pharmacology–identified molecular targets provide system pharmacology interpretation of the synergism of the drugs in clinics. The results suggest that improving vascular health is essential for AD treatment and provide a novel direction for AD drug development.

Refractory Oedema of Nephrotic Syndrome in a Resource Poor Setting: A Case Presentation

Background: Oedema, a constant feature of childhood nephrotic syndrome can be severe, enough to cause respiratory embarrassment. It can also be refractory to diuretic monotherapy. In such cases, combination of salt poor albumin (SPA) infusion and diuretics has remained the best treatment option. However, the cost of SPA has made it practically unavailable in resource-poor settings. It becomes a therapeutic dilemma when nephrotic syndrome patients of financially-constrained caregivers present with refractory anasarca in a resource-poor settings. Case review: We present a seven-year-old boy with relapsed steroid sensitive nephrotic syndrome who presented to Abia State University Teaching Hospital Aba, in respiratory distress with anasarca and a weight of 58 kilograms. SPA could not be accessed due to financial constraints. A decision to use fresh whole blood in the place of SPA, in combination with frusemide, achieved a lifesaving diuresis and regression of the anasarca. Conclusion: Whole blood is a good alternative for the treatment of refractory oedema in children with nephrotic syndrome in resource poor settings.

Pharmacological Properties of Loop Diuretics and Their Clinical Effects

Edematous states caused by an excessesive extracellular fluid retention are major components of cardiovascular and renal disorders including chronic kidney disease, nephrotic syndrome, and heart failure. The use of diuretic drugs from various groups including loop duiretics are important means of pharmacological correction of these clinical conditions. Moreover, diuretics used to lower bood pressure as a part of antihypertensive treatment, reduce cardiovascular events. The response of patients to the dose of a diuretic is reflected by a sigmoid dose-response curve which can be affected by changes of sodium content in the body. Loop diuretics may fail to control salt and water retention despite the use of appropriate doses. The main reasons for loop diuretic resistance may be determined by further reduction of glomerular filtration rate and reduced peak concentration of loop diuretics in primary urine. Chronic treatment with loop diuretics can cause compensatory hyperthrophy of epithelial cells along the ascending limb of the loop of Henle and thus decrease of its diuretic effect. The principles of avoiding this phenomenon are the restriction of sodium intake, correction of doses, timing and frequency of drug administration, and use of combination diuretic therapy. Loop diuretic - related adverse events that involve uricaemia and ototoxicity also should be taken into consideration.

Diuretics Combined With Compression in Resistant Limb Edema of Advanced Disease—A Case Series Report

IntroductionThe extremity edema of advanced disease is a common, multifactorial feature, which impairs patients' activities and quality of life. The most frequently chosen management is based on combined decongestive physiotherapy or pharmacotherapy (with diuretics or steroids). Subcutaneous lymphatic drainage in refractory edema may decrease the swelling, prevent spontaneous lymphorrhea, but also increase the risk of infection. Safe and effective conservative management in diuretics-resistant edemas is lacking. The objective of this prospective, observational study was to assess the effectiveness and tolerability of combined physiotherapeutic and diuretic therapy in edemas refractory to parenteral diuretics. MethodsA group of 19 patients with advanced disease and severe bilateral leg edema resistant to parenteral diuretic therapy were treated for three days with a combination of multilayer short-stretch compression bandaging and furosemide in hypersaline intravenous infusion. ResultsA clinically meaningful decrease in mean limb volume (of 1.52 L; 20.6%; P < 0.0001)—strongly correlating with patients' weight loss (ρ = 0.71; P = 0.0001), with a lowering of the intensity of complaints—was achieved. The treatment was well tolerated, without decreasing the performance status in any patient. Stable levels of blood pressure, laboratory kidney profile (potassium, sodium, creatinine clearance), and serum albumin were observed. Maintenance of the achieved results with a good compliance was seen during an informal follow-up at the hospice. ConclusionThe combination of compression therapy with hypersaline diuretics could be considered as a valuable option for refractory cases of limb edema in advanced disease.

USE OF FUROSEMIDE STRESS TEST FOR EDEMA CONTROL AND PREDICTING ACUTE KIDNEY INJURY IN CHILDREN WITH NEPHROTIC SYNDROME

Background: Furosemide stress test (FST) involves measurement of 2?h urine output after giving 1 mg/kg of furosemide in clinically&nbsp;euvolemic patients and has been shown to identify those with severe and progressive acute kidney injury (AKI). Objectives: To&nbsp;assess whether using FST could help in deciding whether to give diuretics only, or combination of diuretics with albumin infusion,&nbsp;in children with nephrotic syndrome with edema to prevent AKI. Materials and Methods: This prospective, pilot cohort study was&nbsp;conducted on the use of FST to manage edema in children with nephrotic syndrome. Consecutive patients 1–14 years were enrolledfrom October 2016 to April 2017 from the pediatric nephrology outpatient department of a tertiary care center. They were assessed for&nbsp;fluid overload using their present and baseline weight. Patients with fluid overload of ?10% were screened for AKI by measurement&nbsp;of serum urea and creatinine and monitoring of urine output in the next 24 h. Systemic infections were excluded using clinical and&nbsp;laboratory criteria. AKI was defined using the pediatric RIFLE score. Children with fluid overload of ?10% were given intravenous&nbsp;furosemide 1 mg/kg provided; they had no clinical signs of intravascular dehydration or shock. Urine output was measured over thenext 2 h. Children with urine output &lt;1 ml/kg/h after FST were presumed to be at risk for progressive AKI. Differences between&nbsp;the average heart rate, serum albumin, and urea/creatinine ratio were analyzed by independent t?test. Results: A total of 67 children&nbsp;with nephrotic syndrome were reviewed, and 34 with fluid overload of &gt;10% were analyzed for inclusion in the study. Of them,&nbsp;11 were excluded and 23 were finally analyzed. 19/23 had urine output &gt;1 mg/kg/h in next 2 h and none had serum creatinine&nbsp;increase &gt;0.3 mg/dl or &gt;150% of the baseline value. 4 had urine output &lt; 1 ml/kg/h. Significant difference was found in the post?FSTheart rate and urea/creatinine ratio between the children who had urine output &gt;1 ml/kg/h and which had &lt; 1 ml/kg/h after furosemide.&nbsp;These children were assumed to be at risk for severe and progressive AKI as per FST and were thereafter given furosemide with&nbsp;albumin to prevent further intravascular dehydration. Conclusion: FST may be used as a bedside test to help identify the children&nbsp;with nephrotic syndrome with intravascular dehydration who are at high risk for AKI and helps rational use of diuretics.&nbsp

Abstract 23084: Marked Global Variability in Cost Effectiveness of Lipid-Lowering and Combination Antihypertensive Therapies in Primary Prevention: Analyses of the HOPE-3 Trial

Background: The Heart Outcomes Prevention Evaluation (HOPE) - 3 trial demonstrated that low dose lipid-lowering medication alone or with an angiotensin receptor blocker (ARB)+ thiazide resulted in a significantly lower risk of cardiovascular events compared to placebo in intermediate risk persons without cardiovascular disease. Since use of these medications in primary prevention could have significant cost implication, we report the cost analysis of the HOPE-3 trial. Methods: Hospitalization events, procedures, medications and study drugs were extracted for each patient. We applied country-specific costs to healthcare resources consumed for each patient. We calculated average cost per patient for the length of the study (median follow-up 5.6 years). Costs are reported in US dollars and discounted at 3% per year. The costs of the study drugs vary considerably between countries and we use the most locally affordable (generic) lipid-lowering medication and ARB + diuretic combination. Results: In most regions, use of lipid-lowering medication in combination with antihypertensive drugs in HOPE-3 was cost-neutral or cost-saving as the cost of these medications was offset by savings in other costs (events, procedures, and usual medications). Surprisingly, in India and China, the cost of these medications is the main component of overall health expenditures, being more expensive than all other costs. Conclusions: The use of lipid-lowering medication alone or with antihypertensives agents is cost-saving in most regions by providing significant clinical benefit to intermediate risk persons without cardiovascular disease. Prices for these generic drugs in India and particularly in China are high relative to other costs and policies to reduce the prices of these are needed to ensure that generics are more affordable. Primary prevention using lipid-lowering medication and antihypertensive agents would be cost-neutral or cost-saving worldwide.

Prevalence, Risk factors and current prospectus of treatment management of hypertension including obese patients in Jessore, Bangladesh

Background/Objectives: Cardiovascular disease (CVD) is the most concerning disease in health sectors, whole over the world. Some environmental parameters and physical condition affect on the cardiac health. We therefore observed a cross sectional study of cardiac health condition and analysis to effect risks factors study.Methods: This cross sectional study was performed on hypertensive patients with their treatment managements. Study area, study population & sample and data collection were well performed by informative questionnaires. Significance of variants data was analyzed considering p<0.05 by SPSS software.Results: This estimated hypertensive patients data was 25.4% female and 74.6% male. 36 to 50 years holdings patients was to be highest, containing 43.8% and their systolic pressure (Mean SD) was 143.1510.51. Age depending Odds Ratio [confidence interval] for 60 up age patients was 1.996[0.756 - 5.269]. Consideration of BMI index the Odds Ratio (confidence interval) of obese patients was 6.258(2.595 - 15.088). Most choice of treatment managements of hypertensive patients was angiotensine receptor blockers. With hypertension some cardiovascular complication were to be occurred , in these condition some combination drugs were to be referred, most choice of drugs was angiotensine receptor blockers and diuretics combination preparation.Conclusion: Population based cross sectional study in Jessore region was to be estimated cardiovascular diseases and screen out informative knowledge of hypertensive risk factors.

Renal function monitoring in heart failure - what is the optimal frequency? A narrative review.

The second most common cause of hospitalization due to adverse drug reactions in the UK is renal dysfunction due to diuretics, particularly in patients with heart failure, where diuretic therapy is a mainstay of treatment regimens. Therefore, the optimal frequency for monitoring renal function in these patients is an important consideration for preventing renal failure and hospitalization. This review looks at the current evidence for optimal monitoring practices of renal function in patients with heart failure according to national and international guidelines on the management of heart failure (AHA/NICE/ESC/SIGN). Current guidance of renal function monitoring is in large part based on expert opinion, with a lack of clinical studies that have specifically evaluated the optimal frequency of renal function monitoring in patients with heart failure. Furthermore, there is variability between guidelines, and recommendations are typically nonspecific. Safer prescribing of diuretics in combination with other antiheart failure treatments requires better evidence for frequency of renal function monitoring. We suggest developing more personalized monitoring rather than from the current medication‐based guidance. Such flexible clinical guidelines could be implemented using intelligent clinical decision support systems. Personalized renal function monitoring would be more effective in preventing renal decline, rather than reacting to it.