Beta Blocker Withdrawal

Final Case PresentationPresented By: Steven FiedlerPharm.D. Candidate 2015DD

DDCC: I am frustrated, every food I like makes me sickHPI: Last A1c was 8.6% in September 2014. Enrolled in Diabetes Insulin Treat to Target Clinic in October 2014. Upon enrollment, re-started Metformin and Glipizide. When asked about A1c, patient stated, They took me off all my meds, the last time I relapsed they took me off my diabetes medications.DD PMHGERD 10/2006Obesity 10/2006HL 04/2007T2DM 08/2008Insomnia 07/2009Impotence 12/09PTSD 10/10Alcohol dependence 12/11Opioid use with alcohol dependence 11/12Leiomyoma 01/13DVT 12/13HTN 11/14Hematuria 11/14Hypercalcemia 11/14Degenerative arthritis of Lt Knee 11/14Bipolar mania 12/14

DDFH- To be addedSH recovering alcoholic, last relapse was 2 weeks ago. Sister is his support system although she may be abusing him financially and emotionally. Lives at Soldier On , on the hill adjacent to VA.

DD MedicationsMetformin 1000mg;po;BIDGlipizide 5mg;po;BID;WMSimvastatin 40mg;po;HSMetoprolol tartrate 100mg;po;BIDTopiramate 50mg;po;HSTrazodone 100mg;po;HS

Aspirin EC 81mg;po;dailyMVI 1 tablet;po;dailyGlucose 4gm Chew 3 tabs;po;PRN;hypoglycemiaClotrimazole AAA;topically;BIDAcetaminophen 325mg 2 tabs;po;q6;PRN;painRanitidine 150mg;po;BID;PRN;GERD

DDAllergies

ROS The patient reports in overall good affect, no confusion, trauma, shakiness, or any other neurologic symptoms. Patient doesnt really know why he is here, just that he knows his A1c isnt reflective of a true average and that 3 months on his meds and a more motivated diet will get him towards his goals.DD PEGen Obese veteran appearing stated age NAD

VS

HEENT PERRLA, EOMI

Neck/Lymph- supple no LAD

Lungs CTA

DD PECV RRR no MRG

ABD Q4 tenderness, guarding

Genit/Rect deferred

MS/Ext No CC LLE on Rt leg, currently treated with clotrimazole

Neuro A&O x3; CN2-12 intactDD Labs (Date)DD ExamsDD Problem ListT2DM

Alcohol Dependence

-Blocker Withdrawal

Problem #1Type 2 Diabetes Mellitus (T2DM) DDManaged on Metformin and Glipizide and lifestyle modificationsWhen his medication and regimen is working, his A1c is 6-6.9Upon last intake for alcohol intoxication, they discontinued his regimenLast A1c in September was 8.7%Diabetes

Not ThisThisRisk Factors for DiabetesAge 45 yearsFirst-degree relative with diabetes Overweight with central obesity (BMI 25 kg/m2)Hypertension (BP 140/90 mm Hg )Treated for hypertensionHDL cholesterol 250 mg/dLAmerican Diabetes Association. Standards of medical care in diabetes2015. Diabetes Care 2015;30(Suppl 1):S4S41.Signs and Symptoms T2DMPolyuriaPolydipsiaBlurry vision

American Diabetes Association. Standards of medical care in diabetes2015. Diabetes Care 2015;30(Suppl 1):S4S41.Diagnosis of T2DMA1c6.5% Fasting Plasma Glucose126 mg/dL2 hour plasma glucos during an OGTT200 mg/dLRandom Plasma Glucose (w/ classic symptoms) or Hyperglycemic crisis200 mg/dLIn the absence of classic cymptoms, testing should be repeated to confirm diagnosisAmerican Diabetes Association. Standards of medical care in diabetes2015. Diabetes Care 2015;30(Suppl 1):S4S41.Treatment Algorithm for Management of T2DM

Nathan DM, Buse JB, Davidson MB, et al. Medical Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy: A consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2009; 32:193-203.Problem #2Alcohol Dependence (AD)DD12/11 Diagnosed with Alcohol DependenceLOOK UP IN CPRSSigns and Symptoms of AD and WithdrawalSeizure

Confusion

Tremor

Tachycardia

Deep tendon reflexes

Unresponsiveness

Sweating

Shaking

Tachycardia

Mayo-Smith MF. Pharmacological management of alcohol withdrawal: a meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA 1997;278:144151.Lab abnormalities in AD LFTs, including AST/ALT ratio

INR (in the absence of warfarin use)

albumin

Potassium (K+)

Magnesium (Mg+)

Mayo-Smith MF. Pharmacological management of alcohol withdrawal: a meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA 1997;278:144151.DDDD has come into some money and the temptation to leave Soldier On and rent a hotel room for the weekend is too much. He goes downtown and frequents the local watering hole and then returns to his hotel room and goes to the mini-fridge. Once he runs out of money he reluctantly returns to Soldier On and is admitted to urgent care for acute alcohol withdrawal.

Goals of therapyControl acute symptoms of alcohol withdrawal.Prevent progression to delirium tremens and withdrawal seizuresCorrect electrolyte imbalances Start prophylaxis to prevent Wernickes encephalopathy.Enroll patient in a program to help him stop drinkingfollowed by long-term abstinence control.Work up potential liver diseaseprevent further progression. Refer patient to dietitian for assistance with long-term nutritional stabilityMayo-Smith MF. Pharmacological management of alcohol withdrawal: a meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA 1997;278:144151.Wernickes Encephalopathy

TreatmentAlgorithms are set dosing frequency based on the CIWA-Ar Score. The higher the score the greater the loading dose for the Benzodiazepine and then taper gradually.Each hospital follows its own protocol based on symptoms AD treatmentMostly supportive care once the withdrawal is managed.Fluids: NS or NS if Sodium is elevatedElectrolytes: Banana bag (K+, Mg+)Nutrition and Supplements: Thiamine, B12, MVI

Problem #3Beta Blocker WithdrawalDDs presentationRan out of Metoprolol Tartrate 100mgHas been on the medication for yearsStopped taking the medication on Monday due to low supplyDidnt take next dose until Wednesday morning Signs and symptomsSweating

Tumultuous stomach

Racing heart beat

Heart beating out of the chestLefkowitz RJ, Caron MG, Stiles GL. Mechanisms of membrane-receptor regulation. Biochemical, physiological, and clinical insights derived from studies of the adrenergic receptors. N Engl J Med 1984; 310:1570.Sympathomimetic surge

30Stopping B-Blockers Abruptly Can Lead toRapid asymptomatic return of BP to pretreatment levelsSlow asymptomatic return of pretreatment levelsRebound BP with signs and symptoms of sympathetic overactivityOvershoot of BP above pretreatment levels

Houston MC. Abrupt cessation of treatment in hypertension: consideration of clinical features, mechanisms, prevention and management of the discontinuation syndrome. Am Heart J 1981; 102:415.

Pharmocokinetics of B-blockersDrugADMET Atenolol50% Bioavailability6-16% protein bindingHepaticR: 50%F: 50%6-7hBisoprolol80% Bioavailability30% protein bindingHepaticR: 50%9-12hCarvedilol25-35% BioavailabilitySystemic (Vd 115L)Hepatic 2D6S: F/B7-10hMetoprolol50% Bioavailability10% albumin boundHepatic 2D6R: 95%3-4hPropranolol 30-70% Bioavailability93% protein bindingHepatic R: