sachida
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A 58 yr old male of asian origin comes to your clinic for routine evaluation. He is know diabetic and have had good glycemic control with injectable insulin. On examination, his HR 85, BP 150/75 and all systemic examination is within normal limits. His urine has previously demonstrated micro-proteinuria but no glucose.
What will be your best therapeutic option in this patient.
A. Change in lifestyle and control of BP with medidation and biofeedback mechanisms
B. Losartan
C. Enalapril
D. Nifedipine
E. Educate patient to observe for sign and symptoms of uncontrolled diabetes and hypertension
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| MAZI
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choice in DM+ proteinuria is ACE inhibitor( enalapril)
C
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| cyra
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C
Proteinuria in a diabetic warrants administration of ACEI to prevent progression of nephropathy.
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| achilles
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c-enalapril
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| sachida
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I think C is the correct answer. It decreases mortality.
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| AAAAA
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Thank you to everyone in this Forum to answer this question.
But the correct answer is Losartan !!
In Type 1 diabetics, ACEI inhibitors such as Enalapril will reduce mortality.
But Losartan studies among Type 2 diabetics indicated ARB actually reduce mortality among diabetics.
But the real answer is this is an Asian patient.
SELDOM USMLE WILL MENTION THE RACE AND ETHNICITY OF THE PATIENTS.
Among white population, 15% of white patients can not tolerate enalapril (C)
But among Asian population, 50% of Asian patients can not tolerate enalapril (C)
So the correct answer is B Losartan.
This is an unfair question which tested you about different ethnic groups which can not take certain medications.
Just like Italian may not toelrate quidinine !
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| AAAAA
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sachida wrote:
A 58 yr old male of asian origin comes to your clinic for routine evaluation. He is know diabetic and have had good glycemic control with injectable insulin. On examination, his HR 85, BP 150/75 and all systemic examination is within normal limits. His urine has previously demonstrated micro-proteinuria but no glucose.
What will be your best therapeutic option in this patient.
A. Change in lifestyle and control of BP with medidation and biofeedback mechanisms
B. Losartan
C. Enalapril
D. Nifedipine
E. Educate patient to observe for sign and symptoms of uncontrolled
diabetes and hypertension
THE CORRECT ANSWER IS B. LOSARTAN.
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| AAAAA
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Cough and angioedema are the most common side-effects of ACEI among Asian patients and comprises of 50% of the total number of Asian patients usign ACEI !
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| AAAAA
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sachida wrote:
A 58 yr old male of asian origin comes to your clinic for routine evaluation. He is know diabetic and have had good glycemic control with injectable insulin. On examination, his HR 85, BP 150/75 and all systemic examination is within normal limits. His urine has previously demonstrated micro-proteinuria but no glucose.
What will be your best therapeutic option in this patient.
A. Change in lifestyle and control of BP with medidation and biofeedback mechanisms
B. Losartan
C. Enalapril
D. Nifedipine
E. Educate patient to observe for sign and symptoms of uncontrolled diabetes and hypertension
Dr.
It is this kind of question that "kills" us in the examination !@
The question asks you the most common side-effects of ACEI enlapril that can not be tolerated among Asian population.
Once you see a Black patient, you must think about sarcoidosis !!
White patients HHH !
hereditary hemochromatosis
Female patients think rheumatoid diseases, and other immunlogic diseases.
Asian patients also are involves in closed angle glaucoma, cancer of the nose, liver cancer, hepatitis B (congenital transmission), and intolerance of ACEI !!
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| sachida
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ACE inhibitors DO decrease mortality in type II diabetes (http://www.medscape.com/viewarticle/479088?src=mp)
According to latest review from pubmed- whether ACEi and losrtan vary in efficacy has not been tested in diabetics using head to head trial.
" J Hypertens. 2006 Jan;24(1):11-25. Related Articles, Links
Blockade of the renin-angiotensin-aldosterone system: a key therapeutic strategy to reduce renal and cardiovascular events in patients with diabetes.
Burnier M, Zanchi A.
Service de Nephrologie, Department of Medicine, Lausanne Switzerland. michael.burnier@chuv.hospvd.ch
Diabetes (particularly type 2 diabetes) represents a global health problem of epidemic proportions. Individuals with diabetes are not only more likely to develop hypertension, dyslipidemia, and obesity, but are also at a significantly higher risk for coronary heart disease, peripheral vascular disease, and stroke. Angiotensin II plays a key pathophysiological role in the progression of diabetic renal disease, and blockade of the renin-angiotensin system with angiotensin-converting enzyme inhibitors (ACEi) or angiotensin II antagonists has therefore become an important therapeutic strategy to reduce renal and cardiovascular events in patients with diabetes. Several studies have demonstrated the effects of angiotensin II antagonists on the reduction of albuminuria and the progression of renal disease from microalbuminuria to macroalbuminuria. More importantly, several endpoint trials have shown that the antiproteinuric effects of losartan and irbesartan translate into cardiovascular and renoprotective benefits beyond blood pressure lowering, thereby delaying the need for dialysis or kidney transplantation by several years. These and other studies indicate that angiotensin II antagonists not only improve survival and quality of life of patients with diabetic nephropathy, but also have the potential to reduce the substantial healthcare burden associated with managing these patients. ACEi also appear to exert similar beneficial effects in diabetic patients, but whether clinically significant differences in renoprotection or mortality exist between angiotensin II antagonists and ACEi in patients with type 2 diabetes remains to be fully investigated in appropriate head-to-head studies."
However, there is a truth in asian ethnicity and increased incidece on cough.
So if patient can afford, losartan should be choice and in usmle you think they can afford so guru is correct.
Losartan should be the answer
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| AAAAA
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Thanks.
I did take the USMLE and they very, very, very seldom even mention any racial group or single out any racial group. If they do, then there is a red herring, so the answer is B
Losartan !!
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| infliximab
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C
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