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5yr

Complications for an Elderly Patient with Hypertension

A 78-year-old male presented to the local emergency complaining of severe abdominal pain. It was also discovered that he had atrial fibrillation that was newly onset. In addition to being treated for hypertension, the patient was also being medicated for acid reflux. His blood pressure was 135/85 and his heart rate was irregular at 53 beats per minute. His lipid panel revealed a total cholesterol of 311 mg/dl, TG of 252 mg/dl, HDL-C of 37 mg/dl and LDL-C of 222 mg/dl.

Prior to discharge, he asked that his medications be chosen from those approved by his insurance company. Subsequently, he was sent home with 180 mg diltiazem daily, 40 mg simvastatin daily, 500 mg Flagyl daily and 200 mg amiodarone daily.

Less than three weeks afterward, the patient again presented at the emergency room. His complaints included urine that was rusty in color, and severe muscle weakness and pain that was especially pronounced in his thighs and arms. His heart rate was 51 beats per minute and his blood pressure was 96/59. Though he was afebrile, this patient appears to be acutely ill.

Which of his medications would you change and why?

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  • 5yr
    Step one stop meds, step 2 begin fluids and check a CK and renal function as the combination likely caused rhabdo. If he was not evaluated originally he should have had an eval for possible ischemic bowel due to possible embolus from his atrial fib. I would have recommended anticoagulation with Xarelto. His heart rate was already controlled upon initial admission I would not have used diltiazem or amiodarone. I also did not see an indication for flagyl.
    I would have uses a hi intensity statin like crestor and zetia in combination with his initial values possible a PCSK9 if these did not bring him to goal.
  • 5yr
    Step one stop meds, step 2 begin fluids and check a CK and renal function as the combination likely caused rhabdo. If he was not evaluated originally he should have had an eval for possible ischemic bowel due to possible embolus from his atrial fib. I would have recommended anticoagulation with Xarelto. His heart rate was already controlled upon initial admission I would not have used diltiazem or amiodarone. I also did not see an indication for flagyl.
    I would have uses a hi intensity statin like crestor and zetia in combination with his initial values possible a PCSK9 if these did not bring him to goal.
  • 5yr
    I definitively would discontinue Amiodarone, diltiazem, Fagyl and simvastatin. He is now suffering the interactions of the medications combined . Almost every combination has interactions against the other : Flagyl increases effects of Amiodarone, Diltiazem increases effects of Amio, amiodarone increases effects of simvastatin . So now he is presenting Bradycardia , Hypotension and Rhabdo.
    The pt requires acute stabilization and re assessment for medications to be started accordingly to Goals of care HTN < 130/80 , control rate and CHADs score.
    Hyperlipidemia to be treated with no statins medications.
  • 5yr
    He probably has rhabdo related to the simvastatin. I would DC the simvastatin and consider low dose crestor when he recovers. I would DC the amiodarone and decrease the diltiazem due to low BP. I would start eliquis or xarelto due to the Afib and monitor rate and rhythm labs and s/s of bleeding or bruising.
  • 5yr
    I have very little to say after reading the above comments from NP Cronin, it simply does not seem right that patient is placed on this combination of medications, without considering the different drug to drug interactions that exist between them. Pt now very likely has rhabdomyolysis caused by drug interactions. Given that patient now is bradycardia, hypotensive, I would stop all above meds, place him on cardia monitor, monitor labs closely and take actions accordingly.
  • 5yr
    Severe hyperlipidemia with high CV risk needs more than Simvastatin which has interactions with ie Amiodarone with diltiazem, diltiazem with simvastatin, and amiodaron with simvastatin. I would use Rosuvastatin with Zetia or better with Repatha. and substitute a Beta Blocker for Diltiazem. I would not use Flagyl, and I would skip the Amiodarone.
  • 5yr
    I would not put him on Amiodarone due to the current heart rate of 50s, I think diatizem Dose can also be Decreased but I would consider anticoagulant like xerota
  • 5yr
    The patient has Rhagdomyolysis from the Simvastatin and Amiodarone so I would stop them both, After hydration and decrease in CPK levels, I would consider Zetia and Vascepa before restarting a statin like Rosuvastatin. Also since cost is such an issue for him I would try PSK9 inhibitors last because they are so expensive. I would also stop the Diltiazem because it likely contributed to his slowed his heart rate and decreased BP. There are so many other anti-hypertensives to chose from. Also he definitely needs an anti-coagulant. Not sure why he was only on Flagyl for his abdominal pain?
  • 5yr
    Patient has rhabdo, bradycardia-would stop all his meds and monitor his heart rate off rate control is needed start a beta blocker. He definitely needs anticoagulation.LDL is 222-Simvastatin 40 mg will not bring him to goal-would consider Crestor 20mg or Nexlitol.Without amiodarone and Diltiazem he may not develop rhabdo with another statin.He is worried about cost of medication so another statin may be the only option here.
  • 5yr
    Pt would benefit from Vascepa and a PCSK9
  • 5yr
    He probably has rhabdo - they should do CPK (if not cardiac profile) and it is interesting to see BMP. Flagyl can cause urine discoloration, although i drought he was on Flagyl for more that 2 weeks. Plus you don't treat diverticulitis only with Flagyl, needed cipro or levaquin as well. Amiodarone is not at all a first choice for newly diagnosed A-fib, especially with someone with rates in 50s and hypertension was mention, It says that he is being medicated for acid reflux, but no PPI for home - could have GI bleed with the hypotension
  • 5yr
    Monitor closely TFT's while on amiodarone. After all, hypothyroidism can occur here and can aggravate the hyperlipidemia. History indicates probable rhabdomyolysis, so statin is contraindicated here. Therefore best would be to start ezetimibe first . Nexletol is relatively CI after rhabdo episode. It could also precipitate a gout attack. TG are also high , so Vascepa could be used.
  • 5yr
    Patient seems to have Rhabdomyolysis as he is on Simvastatin, Diltiazem and Amiodarone combination. Dose of Simvastatin in this case can not be higher than 20 mg. Besides, I would be reluctant to use high intensity statin therapy once he already has Rhabdomyolysis from one agent. His LDL is 222, and it is likely he has Heterozygous FH. He will do best with PCSK9 inhibitors and that should be approved. He will need long term anticoagulation and he first should be evaluated for Cause of his bleeding since he is hypotensive . he has hematuria which is most likely from Rhabdomyolysis.
  • 5yr
    Rhabdo is the culprit. Definitely stip the statin and at this point theres no use for the rate control. These all seem like the wrong choice meds. Crestor and other statibs are generic and should be approved. Amiodarone isnt a 1st line drug in this case and also, is he gettibg anticoagulant?
  • 5yr
    I would discontinue his amiodarone and simvastatin. I would also discontinue the diltiazem. Both the amiodarone and diltiazem increase the levels of simvastatin leading to rhabdomyalysis. The patient should be started on anticoagulation and atorvastatin once his LFTs and renal function return to baseline.
  • 5yr
    Would stop the amiodarone and diltiazem and simvastatin . No need for rate control at this point . If labs do confirm Rhabdo , then it was due to simvastatin amiodarone interaction . Would start crestor at a later time . Would consider anticoagulation if there are not contraindications . If patient had diverticulitis don’t understand why put only on flagyl ? With severe abdominal pain of first er visit one would expect a higher pulse ? What drug was patient taking for HTN already on first visit ? Seems more information is needed to make accurate assessment and plan .
  • 5yr
    The patient has rhabdomyolysis due to the statin likely due to interaction with amiodarone which should have nit been started. I would stop those. Consider anticoagulant due to atrial fibrillation.
  • 5yr
    His history and presentation are consistent with rhabdomyolysis due to the interaction from simvastatin and amiodarone. The abdominal pain may be due to ischemic bowel related to the atrial fibrillation or diverticulitis. CT is warranted. Upon discharge, simvastatin should not be given. It can either be switched to rosuvastatin 20mg or nexletol.
  • 5yr
    Based on the symptoms and urine, the patient has has rhabdomyolysis. This is caused by the drug interactions simvastatin, would stop simivastatin and amiodarone. Would stop both , add NEXLIZET.

  • 5yr
    Based on the color of his urine and severe muscle weakness, the patient has rhabdomyolysis. This is caused by the drug combination, specifically simvastatin, that he was put on during his first previous visit to the emergency room. With his current symptoms and the need to address the results of his lipid panel, the patient would improve by changing the simvastatin to a nonstatin such as Nexletol.
  • 5yr
    Patient has suffered Rhabdomyolysis due to the drug interaction of Amiodarone and Simvastatin ,and the diltiazem interaction with simvastatin the worst possible drug combination was chosen Simavastatin should have never been prescribed as it is almost an obsolete statin due to the increased incidence of drug interactions and better statins availability , also to lower the LDL of 222 simvastatin 40 mgm would not have been efficacious at all either , All the other statins are also generic now and wonder why would one need an approval by the insurance company to presribe a statin prior to discharge ?? Seems like the abdominal pain was due to diverticulitis as pt was discharrged on Flagyl on the first admission has the CHAD score which would indicate the need for anticogulation for A fib ? Why was not prescribed ? In any event pt is quite ill now his Rhabdo needs to managed aggressively now and further lipid management will depend on his out come from this does not need any lipid management right now , once he recovers well for the Lipid management PCSK-9 inhibtors will be indicated if cost not an issue or the newer drug Nexletol in combination with ezetemibe could be considered
  • 5yr
    I would never have put him on amiodarone as a first-line drug with newly diagnosed atrial fibrillation without some discussion at the specialist level about eventual restoration of sinus rhythm. With an initial heart rate in the 50s I'm sort of puzzled why diltiazem was chosen, too. I don't see any discussion of anticoagulation, either. At this point, however, that kind of questioning is sort of unhelpful--what's done is done--so I'd stop everything on the list and let the dust settle, then decide what he needs.

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