Lasix,Vasotec,Hytrin,Nitropatch- Weight loss problem 
Author Message
 Lasix,Vasotec,Hytrin,Nitropatch- Weight loss problem

My father,
  a diabetic for 30 years- insulin dependent for 10 years,
  had quadruple bypass 6 years ago;  
  had congestive heart failure (CHF) three times over the past six mos.
  has strongly compromised kidneys (but not on dialysis)
  retired physician (perhaps knows 'too much')

Is on:
  Lasix    40 mg 1/day
  Vasotec         every other day
  Hytrin    2 mg  every other day (on off days of Vasotec)
  Nitropatch

Suffering from weight loss.  
When he reduces Lasix he gets fluid in the long and approaces CHF when
he continues he loses weight.  He feels he is at a dead end and has become
very depressed on top of the above problems which futher aggrevates
his condition.

Any way to modify above regimen to fix that?  Any suggestions would be
greatly appreciated.

S. Rastegar



Wed, 09 Jun 1999 03:00:00 GMT
 Lasix,Vasotec,Hytrin,Nitropatch- Weight loss problem


Quote:

>My father,
>  a diabetic for 30 years- insulin dependent for 10 years,
>  had quadruple bypass 6 years ago;  
>  had congestive heart failure (CHF) three times over the past six mos.
>  has strongly compromised kidneys (but not on dialysis)
>  retired physician (perhaps knows 'too much')

First question: has he had any evaluation of the grafts in the last six months?
I ask this because diabetics tend to have accelerated coronary artery
disease in the graft vessels, with relatively early graft occlusion
compared with non-diabetics. Based on the sketchy history given here, it
is possible that one of the major grafts is closing down and causing
ischemia (inadequate {*filter*} flow) to a significant portion of heart muscle,
evidenced by CHF. While generalized occlusion of all the graft vessels is
likely proceeding, the culprit in this case might be a single vessel that
has narrowed more than others. The history provided here does not suggest
that he has undergone any evaluation for narrowing of the grafts or active
ischemia - this might be indicated. If a single vessel or two vessel
problem is identified, it may be amenable to angioplasty or repeat CABG
surgery. If the pump function of the heart has not yet been very very
severely compromised, such revascularization procedures might be quite
beneficial. Evaluations that can be considered (in no particular order
here) include an echocardiogram to assess heart muscle contractile
function, an angiogram to assess narrowing of coronary arteries and a
cardiac stress test to assess for cardiac muscle ischemia.

Secondly: is the diabetes relatively well-controlled? What is the HbA1C trend?
Your father is a retired physician, but his DM may still be rather poorly
controlled. Retired physicians can be a tough bunch (I know by personal
experience in my family :-) not very amenable to new suggestions about
what to do (even if they were in different areas of specialization and
don't know much about DM). The HbA1C level (a measure of % of hemoglobin
that is glycosylated) assesses how good control has been in the last 8-10
weeks. In addition, checks on his {*filter*} glucose levels (fasting in the
mornings and before meals) will provide an idea of whether his {*filter*} sugar
level is under reasonable control or not. Poorly controlled DM can be a
major contributor to worsening CAD.

Thirdly: how's his cholesterol (and HDL and LDL)? These are often grossly
abnormal in diabetics, and do contribute to worsening CAD. In the drug
list given below, you do not list any hypolipidemic agent. Simply
controlling the DM may not be enough.

Quote:

>Is on:
>  Lasix    40 mg 1/day
>  Vasotec         every other day
>  Hytrin    2 mg  every other day (on off days of Vasotec)
>  Nitropatch

You have not given any specifics about his renal function; however, the
fact that he continues to be on Vasotec (?dose and apparently being given
every alternate day) suggests that he is able to tolerate it without
serious hypotension or significant hyperkalemia (elevated potassium
level). If either of these had developed (esp. the latter), Vasotec would
probably have been removed from his list altogether. The fact that he
continues to be on it suggests there may be room for increasing the
dose/frequency without major side effects. While it will be beneficial
from the point of view of BP, DM and importantly by improving the pumping
function of the heart, it has to be done very cautiously, keeping a very
close watch on his renal function and serum electrolyte (potassium)
levels. That he is on Hytrin on the days he is not on Vasotec suggests it
is being used to control BP - how is his BP doing? Is it high all the
time? Or is it "normal"/low (could be signs of very severe heart failure)
and characterized by major dips soon after a dose either Vasotec or
Hytrin? From what you have written, his BP may really need to be addressed
- if it is high all the time, it is indicative of need for increasing the
dose of Vasotec within the limits of toleration by his kidneys.
Alternatively he might need to be started on another antihypertensive for
effective BP control.

There may also be room for altering the doses/frequencies of the other
medications. Is he getting enough of the nitropatch? Does he ever have
chest pain/CHF while on the patch? Note that diabetics may have ischemia
without the classical chest pain symptoms, esp. when DM is long-standing.
In some, acute CHF may be the only clue to active ischemia.Maybe he can be
switched to {*filter*}long acting nitrates (or they can be given additionally).

Quote:

>Suffering from weight loss.  
>When he reduces Lasix he gets fluid in the long and approaces CHF when
>he continues he loses weight.  He feels he is at a dead end and has become
>very depressed on top of the above problems which futher aggrevates
>his condition.

Body weight can be confusing in a person with heart failure - there will
obviously be fluctuation in apparent body weight as the body eliminates
edema fluid as urine after each dose of Lasix. The important thing to try
to track is "dry body weight" or an estimate of it. If there is a
significant loss of non-edema weight, it could be because of cardiac
cachexia. Alternatively, given his likely age (you don't mention it) other
possibilities such as malignancies need to be considered and checked for.
There is a long list of possibilities explaining weight loss in the
elderly, and a good physical exam and questioning session is very
important.

One important suggestion is that there not be too many people directing
care at the same time. In today's style of medical practice, patients with
multiple complicated problems often get buffeted around from one
specialist to another - while care is ongoing, there are often
contradictory recommendations about important things such as which
medications to use and the right dose and frequency. Often, changes are
made on the fly by one person because he or she is seeing that day's
problems while unable to see the larger trend and bigger picture of the
patient's overall condition which were the basis for another doctor's
decisions. It might be better to have ONE doctor making most of the
decisions, with limited consultation as and when needed.

Quote:

>Any way to modify above regimen to fix that?  Any suggestions would be
>greatly appreciated.

>S. Rastegar

Only a physician actually evaluating the patient could/should make such
suggestions after fully assessing the patient and all relevant labs/tests.
Your father, being a physician, may feel happier if participates in
decisions and is allowed some leeway in titrating medication doses (within
guidelines established by his doctors); conditions such as CHF are often
best treated by adjusting medication doses to clinical conditions rather
than sticking rigidly to certain doses and schedules. Any intelligent
person can easily assess his own symptoms and participate in the process.
I've seen at least one person with severe CHF that was considered
hopeless, who was given a new lease on life by an astute cardiologist who
took charge of his care and carefully titrated medication doses. The
patient had a significant reduction in hospital and ER visits and felt
much better.

The medication list doesn't mention Aspirin - its useful and should be
given unless contraindicated in the individual patient. Check with his
doctor if he's not on it.

Very important disclaimer: The points mentioned in my response to your
posting are only suggestions for discussion with the patient's
physician(s). The above responses to your posting on the internet
newsgroup sci.med.cardiology are not to be construed in any way as medical
consultation. A doctor-patient relationship does not exist because of any
such responses to your queries over the internet. All medical evaluations,
care, interventions and/or modifications to current therapy should only be
made by and in consultation with the patient's regular physician(s). The
opinions expressed here are of general nature, not necessarily complete
and cannot be readily applied to a specific patient.

Hope all this helps. Don't be put off by that lengthy disclaimer statement
- I just felt it was necessary (this is the first time I am replying to
such a posting and I'm sure someone will be quick enough to comment on it
and suggest alternatives:-). I don't see any other responses here so I
decided to chip in despite the time that has elapsed since your posting (I
don't usually read this newsgroup).

Sincerely,
-S.A.Krishna, MD (IM, not cardio)



Mon, 05 Jul 1999 03:00:00 GMT
 Lasix,Vasotec,Hytrin,Nitropatch- Weight loss problem

[...much omitted...]

Quote:
>Hope all this helps. Don't be put off by that lengthy disclaimer statement
>- I just felt it was necessary (this is the first time I am replying to
>such a posting and I'm sure someone will be quick enough to comment on it
>and suggest alternatives:-). I don't see any other responses here so I
>decided to chip in despite the time that has elapsed since your posting (I
>don't usually read this newsgroup).

>Sincerely,
>-S.A.Krishna, MD (IM, not cardio)

Thank you for a very clear and comprehensive posting.

Bye,



Wed, 07 Jul 1999 03:00:00 GMT
 
 [ 3 post ] 

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