Mr DM has been diagnosed with Diabetes Type 2 (DM2), CKD (Chronic Kidney Damage), COPD (chronic obstructive pulmonary disease). Gout, Mild OA (Osteoarthritis) and HT (total hyperopia). As the nature of DM2 is, if it not managed early, it may leads to other complications such as blindness and skin insensitivity. With Chronic Kidney Damage, the patient can only hope for the recently discovered therapeutic strategies to manage the disease that has already affected the kidneys.4
Due to historical evidence of smoking, COPD may have been one of the side effects. Presence of gout will make the case of this patient clinically complex due to age factor, drug-drug interactions, co-morbidities and refractory tophaceous disease. Although Osteoarthritis is manageable, it is likely to have notable health effects on Mr. DM’s health in the future. In addition, total hyperopia could have come as a result diabetes mellitus type two complications. Total hyperopia will make it harder for Mr. DM to get about with his daily activities including getting to his regular clinical checkups.
According to data from Australian Heart Foundation, Mr. DM is at an extremely high risk of getting into an irrecoverable condition. With all these complications, Mr. DM’s life is all at risk, with minimal chances of survival.
As one of the most basic pharmacologic therapy for type 2 Diabetes (DM2), change of lifestyle should be the first option for Mr. DM. Additionally, addition of metformin treatment would be preferable as initial pharmacological therapy if he can tolerate it. However due to his condition of CKD, the patient may only be recommended with serum creatinine levels of not more than or equal to 1.5 mg/dL daily.12
COPD is a preventable and treatable disease that that leads to a progressive lung malfunctioning. To prevent occurrence of exacerbations, there should be effective management of COPD in order to improve the general quality of life of the patient, and to improve the functionality of the lungs. This would be aimed at reducing the risk of mortality. However, oxygen therapy would also reduce mortality in a great way. With COPD, it is a preventable and treatable disease, and MR DM just needs to be encouraged to be positive minded especially in carrying out the necessary therapies. According to therapeutic guidelines, interventions are advocated according to the severity of COPD. In the case of Mr. DM, long-acting bronchodilator therapy should be initiated.
The major risk factor for CKD here would include cardiovascular diseases and hypertension.7 Other factors risk would include old age, family history, and Native American or African American ethnicity. According to therapeutic guideline, cardiovascular disease and hypertension cases would be more effective with patients with more than 1-3 % CKD as compared to patients with a 5% CKD.6 For this particular case, cardiovascular disease prevalence is likely to increase up to 36% in the case of occurence of CKD. In the event that if first-line agents fail, prednisone or prednisolone administered at a low dosage of <10 mg daily may be recommended as a second-line option.
According to the Canadian Society of Nephrology, the estimated glomerular filtrations for CKD could be at the rate of < 60 mL/min/1.73 m2 3. The best management approach for this condition for the case of Mr. DM would be management of the risk factors of cardiovascular management. It should be noted that the greatest risk factor for chronic kidney disease would be death from cardiovascular illnesses or diabetic complications.1 Most cases of CDK can be managed without referrals to nephrologists. Referral for neurologist is usually recommended when patients are noticed to have acute kidney failure, with a glomerular filtration rate of not less than 30 mL/min/1.72 m2.
Osteoarthritis (OA) is a disease that destabilizes biological and mechanical events of the body that often leads to a decline in the production of articular cartilage of the sub-chondral bone.5 The severity of this condition could get worse for Mr. MD due to the age factor.
Gout is a form of inflammatory arthritis that is known to be very painful.3 This disease occurs in the even where deposits of hyperemic monosodium uprate crystals are found to be deposited in tissues and joints. It has been observed that almost 40% of patients with gout haven been found to have CKD.8 Incidence of gout has been known to increase as the functions of the kidneys decrease. While there is no much evidence that gout can be precipitated by from gemcitabine chemotherapy, the Therapeutic guideline recommends carrying this therapy moderately with measured medications of prophylactic in order to precipitate gout to a manageable remission status, coupled with administering of the prophylactic medications which would involve 100%mg of allopurinol by mouth daily and 0.6%mg of colchicine by mouth daily.9 This medication has been known to suppress even signs of gouty arthritis. However, Multiple DB-RCT evidence has shown that exposing gout patients with hyperemic may expose them to worse renal complications.9, 10 Loop diuretics and thiazide medications may cause contraindications to many patients. Therefore, according to guidelines that have been recently published by the Therapeutic Guidelines, those patients with a contraindication or intolerance to allopurinol have been recommended to use febuxostat.14 If Febuxostat and Xanthine oxidase inhibitors (XOIs) fail, allopurinol can be used as second line options as long as the patient is under anti-inflammatory management. Probenecid agent can also be used in place of the allopurinol as a ULT agent alternative in the event that the patient cannot tolerate XOIs or if they are ineffective. However, for patients with creatinine clearance of <50 ml/min, probenecid is not recommended for them.12
The current treatment guidelines exposes may expose patients to fibrinolysis therapy risks with no likely benefit and may lead to augmentation of false-positive cardiac catheterization which may bring about unnecessary costs in the long-term management of the condition.13 Therefore, it is clear that alternative treatment are needed for Mr. DM. exposing Mr. DM to electrocardiographic (ECG) diagnosis may lead to a certain eventual death due to risk of heart failure and heart attack arrest.16
For the case of Mr. MD, allopurinol initial dose should be within the specifics of <100 mg per day and <50 mg per day because of his case of CKD. Starting this medication at a low dosage may decrease his gout flares that may be associated with ULT. Furthermore, starting the medication at a lower dosage may likely brig down allopurinol hypersensitivity risk and other associated side effects.
With time, the dosage of Allopurinol should be progressively augmented as per the noted levels of serum acid and the clinical recommendations as part of the long term management of gout in the presence of CKD.15 The maintenance dosage can be maintained at >300 mg per day with a consistent monitoring for hypersensitivity.15
For long-term management of gout, long-term prophylaxis with ULT is recommended while ULT is to maintain serum urate levels below a constant6 mg/dl.
For longer management of CKD, Febuxostat renal dose adjustment may not be needed. For short term management of CKD however, the minimum starting dose can be 40 mg per day, in alignment with the FDA-approved dose of 80 mg per day.
Individuals with LBBB make part of approximately 2% of patients who have ACS.14 According to studies5-7 that have been performed more than twenty years ago in the clinical field, it is recommended that, as one of the long-term management of LBBB, Mr. DM should undergo reperfusion therapy with percutaneous coronary intervention (PCI).
For the case of gout, Mr. DM should increase his daily intakes of Ibuprofen to 400 mg daily instead of 400 mg daily intake. 2400mg daily intake of ibuprofen will lead to a complete resolution of gout, within 72 hours, as has been evidenced by studies4-8 in the clinical field. However, as one of the long-term strategies of maintaining Osteoarthritis, ibuprofen, naproxen, diclofenac, and tolmetin have been found to be equally effective in suppressing Osteoarthritis.16
However, it is important to note that patients with LBBB and are older than 65 have a greater burden of comorbidities and risk factors.
If treated less aggressively, myocardial infarction patients with a presumed rate of LBBB may not receive aspirins or undergo coronary interventions. However, addition studies are required to maximize the benefit from of an early treatment strategy that is invasive.
In this treatment plan, allopurinol dosing algorithm which is based on creatinine clearance has not been suggested because it is not evidence based.
In addition to the therapeutic interventional that have been suggested in this plan, as of the treatment strategies of CKD and gout, patient self-management education ids one of the most effective evidence based interventions. Pharmacological and non-pharmacological interventions should be judiciously integrated and maintained indefinitely. Furthermore, in order to prevent gout from recurring,
Since acute flares are associated with low serum uric acid levels, ULT has always been considered as a mainstay treatment for gout management. However, care should be taken in the administering of this treatment because ULT is always associated with severe gout attacks.2-4
It is important to note that low-dose non-steroidal anti-inflammatory drugs and low-dose colchicine drugs are regarded as first line treatment agents while prednisolone and low-dose oral prednisone are considered second-line agents. In the patients with CKD, non-steroidal anti-inflammatory drugs are considered to cause worsening of GFR and all cause contraindications in all stages of CKD.
Pharmacological therapy for gout flares should be started as early as possible since pains from acute gout flares can be excruciating.10 To achieve the most effective relief, treatment should be started at least within 24 hours. Oral corticosteroids are a good choice for relieving pain and inflammation can be a good consideration for people with CKD. Additionally, note that corticosteroids are not to be necessarily contraindicated for patients with diabetes mellitus two.
Additional treatments for treatment of gout that have not been mentioned in this treatment plan include corticosteroids and colchicine due to lack of evidence. The therapeutic guidelines does not recognize these treatment guidelines due to lack of evidence. In a wider consideration, drug choice for any disease and complication should involve a consideration of patient comorbidities. As a general rule, NSAIDs should be avoided for patients with CKD.
References
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