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What is your blood sodium ? If it is low than you have Hyponatremia and belive

if this is the case The VA should have admitted you until NA returned to normal.

Hyponatremia — Comprehensive overview covers symptoms, causes and treatments of

low blood sodium.

definition

Definition

Hyponatremia is a condition that occurs when the level of sodium in your blood

is abnormally low.

Sodium is an electrolyte, and it helps regulate the amount of water that's in

and around your cells. In hyponatremia, one or more factors — ranging from an

underlying medical condition to drinking too much water during endurance sports

— causes the sodium in your body to become diluted. When this happens, your

body's water levels rise, and your cells begin to swell. This swelling can cause

many health problems, from mild to severe.

Hyponatremia treatment is aimed at resolving the underlying condition. Depending

on the cause of hyponatremia, you may simply need to cut back on how much you

drink. In other cases of hyponatremia, you may need intravenous fluids and

medications.

symptoms

Symptoms

Hyponatremia signs and symptoms may include:

Nausea and vomiting

Headache

Confusion

Loss of energy

Fatigue

Restlessness and irritability

Muscle weakness, spasms or cramps

Seizures

Unconsciousness

Coma

More likely you low blood CO2 is due to low K or low O2 not low sodium. You also

must have a hyperventilation problem

Low carbon dioxide (CO2) in the body, or hypocapnia, causes blood to be less

acidic. This condition is caused by hyperventilation, or excessive ventilation.

It leads to a loss of carbon dioxide from the blood. It can be done on purpose,

but mostly it is involuntary. CO2 is usually eliminated from the body rather

quickly. The majority of it is transported through the blood as bicarbonate,

only to be transformed back into CO2 once it has reached the lungs. This process

helps to regulate the acid/alkaline balance in the body.

Read more: What Causes Low Co2 Levels? | eHow.com

http://www.ehow.com/list_6688437_causes-low-co2-levels_.html#ixzz1cpYIFxLn

>

> Had a " Francis Experience " when tech wanted to take temp while taking BP! She

started to head for my ear and I shook my head no. Continued and ran into

hearing aid. Asked me to remove it and I shook head No again and held up 1

finger (index not middle). She got the message and waited!

>

> Saw Dr. K., the new Nepr. and you will never guess what his first question

was: " So, have you got some BP charts for me? " Now there is a doctor that

reviews the chart and obviously hasn't read the VA SOP manual! He thought he

" could live with those numbers " and smiled when I asked if he thought I could!

>

> He then proceded to latest lab and said his only concern was my Carbon Dioxide

numbers were going down (June 7=23, June 24=16, Oct 24=18 range=20 - 30). He

drew a picture and blamed it on low sodium causing excess acid (blood

bicarbonate level HC03). Said he wasn't making changes today but wanted me to

be aware since he would be making recomendations for a new med if the trend

continues. Guess I've got some researching to do!

>

> We talked about switching from Spiro to Epler and he saiid that would have to

come from an Endo! Love the runaround! He cautioned me that it might not

resolve the Gynecomastia and did I know what the next step was. I asked if it

was I shave my beard and buy a dress! I then told him as far as I know it was

AVS and removal or live with it. He made an endo referral!

>

> In the 6months he's been gone he gained alot of people skills. I thought we

had a good appt. and he seemed to know about the ACCORD study and had an

understanding where JNC8 is headed.

>

> - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with previous rt.

flank pain. Treating with Meds. And DASH. . Current BP(last week ave): 131/76

HR 60

> Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and PTSD.

> Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg asprin,

Metformin 2000MG and Spironolactone 50 MG.

>

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Share on other sites

This get as many things as possable must me something new in the VA.

They are also pushing the HIV testing. Not that this is a bad thing.

>

> Had a " Francis Experience " when tech wanted to take temp while taking BP! She

started to head for my ear and I shook my head no. Continued and ran into

hearing aid. Asked me to remove it and I shook head No again and held up 1

finger (index not middle). She got the message and waited!

>

> Saw Dr. K., the new Nepr. and you will never guess what his first question

was: " So, have you got some BP charts for me? " Now there is a doctor that

reviews the chart and obviously hasn't read the VA SOP manual! He thought he

" could live with those numbers " and smiled when I asked if he thought I could!

>

> He then proceded to latest lab and said his only concern was my Carbon Dioxide

numbers were going down (June 7=23, June 24=16, Oct 24=18 range=20 - 30). He

drew a picture and blamed it on low sodium causing excess acid (blood

bicarbonate level HC03). Said he wasn't making changes today but wanted me to

be aware since he would be making recomendations for a new med if the trend

continues. Guess I've got some researching to do!

>

> We talked about switching from Spiro to Epler and he saiid that would have to

come from an Endo! Love the runaround! He cautioned me that it might not

resolve the Gynecomastia and did I know what the next step was. I asked if it

was I shave my beard and buy a dress! I then told him as far as I know it was

AVS and removal or live with it. He made an endo referral!

>

> In the 6months he's been gone he gained alot of people skills. I thought we

had a good appt. and he seemed to know about the ACCORD study and had an

understanding where JNC8 is headed.

>

> - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with previous rt.

flank pain. Treating with Meds. And DASH. . Current BP(last week ave): 131/76

HR 60

> Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and PTSD.

> Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg asprin,

Metformin 2000MG and Spironolactone 50 MG.

>

Link to comment
Share on other sites

Guess he has not had much experience with Spiro side effects. Any HTN expert should be able to prescribe eplerenone so must not be a htn expert or specialist. May your pressure be low!CE Grim MS, MDSpecializing in DifficultHypertension

Had a "Francis Experience" when tech wanted to take temp while taking BP! She started to head for my ear and I shook my head no. Continued and ran into hearing aid. Asked me to remove it and I shook head No again and held up 1 finger (index not middle). She got the message and waited!

Saw Dr. K., the new Nepr. and you will never guess what his first question was: "So, have you got some BP charts for me?" Now there is a doctor that reviews the chart and obviously hasn't read the VA SOP manual! He thought he "could live with those numbers" and smiled when I asked if he thought I could!

He then proceded to latest lab and said his only concern was my Carbon Dioxide numbers were going down (June 7=23, June 24=16, Oct 24=18 range=20 - 30). He drew a picture and blamed it on low sodium causing excess acid (blood bicarbonate level HC03). Said he wasn't making changes today but wanted me to be aware since he would be making recomendations for a new med if the trend continues. Guess I've got some researching to do!

We talked about switching from Spiro to Epler and he saiid that would have to come from an Endo! Love the runaround! He cautioned me that it might not resolve the Gynecomastia and did I know what the next step was. I asked if it was I shave my beard and buy a dress! I then told him as far as I know it was AVS and removal or live with it. He made an endo referral!

In the 6months he's been gone he gained alot of people skills. I thought we had a good appt. and he seemed to know about the ACCORD study and had an understanding where JNC8 is headed.

- 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with previous rt. flank pain. Treating with Meds. And DASH. . Current BP(last week ave): 131/76 HR 60

Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and PTSD.

Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg asprin, Metformin 2000MG and Spironolactone 50 MG.

Link to comment
Share on other sites

No only if low Na causing Sx would adm be indicated and then if not sx rhe adjusting meds as possible causes had been stoppedMay your pressure be low!CE Grim MS, MDSpecializing in DifficultHypertension

What is your blood sodium ? If it is low than you have Hyponatremia and belive if this is the case The VA should have admitted you until NA returned to normal.

Hyponatremia — Comprehensive overview covers symptoms, causes and treatments of low blood sodium.

definition

Definition

Hyponatremia is a condition that occurs when the level of sodium in your blood is abnormally low.

Sodium is an electrolyte, and it helps regulate the amount of water that's in and around your cells. In hyponatremia, one or more factors — ranging from an underlying medical condition to drinking too much water during endurance sports — causes the sodium in your body to become diluted. When this happens, your body's water levels rise, and your cells begin to swell. This swelling can cause many health problems, from mild to severe.

Hyponatremia treatment is aimed at resolving the underlying condition. Depending on the cause of hyponatremia, you may simply need to cut back on how much you drink. In other cases of hyponatremia, you may need intravenous fluids and medications.

symptoms

Symptoms

Hyponatremia signs and symptoms may include:

Nausea and vomiting

Headache

Confusion

Loss of energy

Fatigue

Restlessness and irritability

Muscle weakness, spasms or cramps

Seizures

Unconsciousness

Coma

More likely you low blood CO2 is due to low K or low O2 not low sodium. You also must have a hyperventilation problem

Low carbon dioxide (CO2) in the body, or hypocapnia, causes blood to be less acidic. This condition is caused by hyperventilation, or excessive ventilation. It leads to a loss of carbon dioxide from the blood. It can be done on purpose, but mostly it is involuntary. CO2 is usually eliminated from the body rather quickly. The majority of it is transported through the blood as bicarbonate, only to be transformed back into CO2 once it has reached the lungs. This process helps to regulate the acid/alkaline balance in the body.

Read more: What Causes Low Co2 Levels? | eHow.com http://www.ehow.com/list_6688437_causes-low-co2-levels_.html#ixzz1cpYIFxLn

>

> Had a "Francis Experience" when tech wanted to take temp while taking BP! She started to head for my ear and I shook my head no. Continued and ran into hearing aid. Asked me to remove it and I shook head No again and held up 1 finger (index not middle). She got the message and waited!

>

> Saw Dr. K., the new Nepr. and you will never guess what his first question was: "So, have you got some BP charts for me?" Now there is a doctor that reviews the chart and obviously hasn't read the VA SOP manual! He thought he "could live with those numbers" and smiled when I asked if he thought I could!

>

> He then proceded to latest lab and said his only concern was my Carbon Dioxide numbers were going down (June 7=23, June 24=16, Oct 24=18 range=20 - 30). He drew a picture and blamed it on low sodium causing excess acid (blood bicarbonate level HC03). Said he wasn't making changes today but wanted me to be aware since he would be making recomendations for a new med if the trend continues. Guess I've got some researching to do!

>

> We talked about switching from Spiro to Epler and he saiid that would have to come from an Endo! Love the runaround! He cautioned me that it might not resolve the Gynecomastia and did I know what the next step was. I asked if it was I shave my beard and buy a dress! I then told him as far as I know it was AVS and removal or live with it. He made an endo referral!

>

> In the 6months he's been gone he gained alot of people skills. I thought we had a good appt. and he seemed to know about the ACCORD study and had an understanding where JNC8 is headed.

>

> - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with previous rt. flank pain. Treating with Meds. And DASH. . Current BP(last week ave): 131/76 HR 60

> Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and PTSD.

> Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg asprin, Metformin 2000MG and Spironolactone 50 MG.

>

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Share on other sites

Which medications can cause low NA? I always have it low for last year. Now it's 129, and it's good for me. Natalia To: "hyperaldosteronism " <hyperaldosteronism >Sent: Saturday, November 5, 2011 11:42 AMSubject: Re: Re: Neperologist Appt. Update

No only if low Na causing Sx would adm be indicated and then if not sx rhe adjusting meds as possible causes had been stoppedMay your pressure be low!CE Grim MS, MDSpecializing in DifficultHypertension

What is your blood sodium ? If it is low than you have Hyponatremia and belive if this is the case The VA should have admitted you until NA returned to normal.

Hyponatremia — Comprehensive overview covers symptoms, causes and treatments of low blood sodium.

definition

Definition

Hyponatremia is a condition that occurs when the level of sodium in your blood is abnormally low.

Sodium is an electrolyte, and it helps regulate the amount of water that's in and around your cells. In hyponatremia, one or more factors — ranging from an underlying medical condition to drinking too much water during endurance sports — causes the sodium in your body to become diluted. When this happens, your body's water levels rise, and your cells begin to swell. This swelling can cause many health problems, from mild to severe.

Hyponatremia treatment is aimed at resolving the underlying condition. Depending on the cause of hyponatremia, you may simply need to cut back on how much you drink. In other cases of hyponatremia, you may need intravenous fluids and medications.

symptoms

Symptoms

Hyponatremia signs and symptoms may include:

Nausea and vomiting

Headache

Confusion

Loss of energy

Fatigue

Restlessness and irritability

Muscle weakness, spasms or cramps

Seizures

Unconsciousness

Coma

More likely you low blood CO2 is due to low K or low O2 not low sodium. You also must have a hyperventilation problem

Low carbon dioxide (CO2) in the body, or hypocapnia, causes blood to be less acidic. This condition is caused by hyperventilation, or excessive ventilation. It leads to a loss of carbon dioxide from the blood. It can be done on purpose, but mostly it is involuntary. CO2 is usually eliminated from the body rather quickly. The majority of it is transported through the blood as bicarbonate, only to be transformed back into CO2 once it has reached the lungs. This process helps to regulate the acid/alkaline balance in the body.

Read more: What Causes Low Co2 Levels? | eHow.com http://www.ehow.com/list_6688437_causes-low-co2-levels_.html#ixzz1cpYIFxLn

>

> Had a "Francis Experience" when tech wanted to take temp while taking BP! She started to head for my ear and I shook my head no. Continued and ran into hearing aid. Asked me to remove it and I shook head No again and held up 1 finger (index not middle). She got the message and waited!

>

> Saw Dr. K., the new Nepr. and you will never guess what his first question was: "So, have you got some BP charts for me?" Now there is a doctor that reviews the chart and obviously hasn't read the VA SOP manual! He thought he "could live with those numbers" and smiled when I asked if he thought I could!

>

> He then proceded to latest lab and said his only concern was my Carbon Dioxide numbers were going down (June 7=23, June 24=16, Oct 24=18 range=20 - 30). He drew a picture and blamed it on low sodium causing excess acid (blood bicarbonate level HC03). Said he wasn't making changes today but wanted me to be aware since he would be making recomendations for a new med if the trend continues. Guess I've got some researching to do!

>

> We talked about switching from Spiro to Epler and he saiid that would have to come from an Endo! Love the runaround! He cautioned me that it might not resolve the Gynecomastia and did I know what the next step was. I asked if it was I shave my beard and buy a dress! I then told him as far as I know it was AVS and removal or live with it. He made an endo referral!

>

> In the 6months he's been gone he gained alot of people skills. I thought we had a good appt. and he seemed to know about the ACCORD study and had an understanding where JNC8 is headed.

>

> - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with previous rt. flank pain. Treating with Meds. And DASH. . Current BP(last week ave): 131/76 HR 60

> Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and PTSD.

> Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg asprin, Metformin 2000MG and Spironolactone 50 MG.

>

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Share on other sites

If cause of low blood CO2 is related to low salt as he was told seem like it

would also be causeing Sx of low salt.

> > >

> > > Had a " Francis Experience " when tech wanted to take temp while taking BP!

She started to head for my ear and I shook my head no. Continued and ran into

hearing aid. Asked me to remove it and I shook head No again and held up 1

finger (index not middle). She got the message and waited!

> > >

> > > Saw Dr. K., the new Nepr. and you will never guess what his first question

was: " So, have you got some BP charts for me? " Now there is a doctor that

reviews the chart and obviously hasn't read the VA SOP manual! He thought he

" could live with those numbers " and smiled when I asked if he thought I could!

> > >

> > > He then proceded to latest lab and said his only concern was my Carbon

Dioxide numbers were going down (June 7=23, June 24=16, Oct 24=18 range=20 -

30). He drew a picture and blamed it on low sodium causing excess acid (blood

bicarbonate level HC03). Said he wasn't making changes today but wanted me to be

aware since he would be making recomendations for a new med if the trend

continues. Guess I've got some researching to do!

> > >

> > > We talked about switching from Spiro to Epler and he saiid that would have

to come from an Endo! Love the runaround! He cautioned me that it might not

resolve the Gynecomastia and did I know what the next step was. I asked if it

was I shave my beard and buy a dress! I then told him as far as I know it was

AVS and removal or live with it. He made an endo referral!

> > >

> > > In the 6months he's been gone he gained alot of people skills. I thought

we had a good appt. and he seemed to know about the ACCORD study and had an

understanding where JNC8 is headed.

> > >

> > > - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with previous rt.

flank pain. Treating with Meds. And DASH. . Current BP(last week ave): 131/76 HR

60

> > > Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and PTSD.

> > > Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg asprin,

Metformin 2000MG and Spironolactone 50 MG.

> > >

> >

> >

>

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Share on other sites

Some diabetes meds. Some just have osmo receptor reset if been there for some time. May your pressure be low!CE Grim MS, MDSpecializing in DifficultHypertension

Which medications can cause low NA? I always have it low for last year. Now it's 129, and it's good for me. Natalia To: "hyperaldosteronism " <hyperaldosteronism >Sent: Saturday, November 5, 2011 11:42 AMSubject: Re: Re: Neperologist Appt. Update

No only if low Na causing Sx would adm be indicated and then if not sx rhe adjusting meds as possible causes had been stoppedMay your pressure be low!CE Grim MS, MDSpecializing in DifficultHypertension

What is your blood sodium ? If it is low than you have Hyponatremia and belive if this is the case The VA should have admitted you until NA returned to normal.

Hyponatremia — Comprehensive overview covers symptoms, causes and treatments of low blood sodium.

definition

Definition

Hyponatremia is a condition that occurs when the level of sodium in your blood is abnormally low.

Sodium is an electrolyte, and it helps regulate the amount of water that's in and around your cells. In hyponatremia, one or more factors — ranging from an underlying medical condition to drinking too much water during endurance sports — causes the sodium in your body to become diluted. When this happens, your body's water levels rise, and your cells begin to swell. This swelling can cause many health problems, from mild to severe.

Hyponatremia treatment is aimed at resolving the underlying condition. Depending on the cause of hyponatremia, you may simply need to cut back on how much you drink. In other cases of hyponatremia, you may need intravenous fluids and medications.

symptoms

Symptoms

Hyponatremia signs and symptoms may include:

Nausea and vomiting

Headache

Confusion

Loss of energy

Fatigue

Restlessness and irritability

Muscle weakness, spasms or cramps

Seizures

Unconsciousness

Coma

More likely you low blood CO2 is due to low K or low O2 not low sodium. You also must have a hyperventilation problem

Low carbon dioxide (CO2) in the body, or hypocapnia, causes blood to be less acidic. This condition is caused by hyperventilation, or excessive ventilation. It leads to a loss of carbon dioxide from the blood. It can be done on purpose, but mostly it is involuntary. CO2 is usually eliminated from the body rather quickly. The majority of it is transported through the blood as bicarbonate, only to be transformed back into CO2 once it has reached the lungs. This process helps to regulate the acid/alkaline balance in the body.

Read more: What Causes Low Co2 Levels? | eHow.com http://www.ehow.com/list_6688437_causes-low-co2-levels_.html#ixzz1cpYIFxLn

>

> Had a "Francis Experience" when tech wanted to take temp while taking BP! She started to head for my ear and I shook my head no. Continued and ran into hearing aid. Asked me to remove it and I shook head No again and held up 1 finger (index not middle). She got the message and waited!

>

> Saw Dr. K., the new Nepr. and you will never guess what his first question was: "So, have you got some BP charts for me?" Now there is a doctor that reviews the chart and obviously hasn't read the VA SOP manual! He thought he "could live with those numbers" and smiled when I asked if he thought I could!

>

> He then proceded to latest lab and said his only concern was my Carbon Dioxide numbers were going down (June 7=23, June 24=16, Oct 24=18 range=20 - 30). He drew a picture and blamed it on low sodium causing excess acid (blood bicarbonate level HC03). Said he wasn't making changes today but wanted me to be aware since he would be making recomendations for a new med if the trend continues. Guess I've got some researching to do!

>

> We talked about switching from Spiro to Epler and he saiid that would have to come from an Endo! Love the runaround! He cautioned me that it might not resolve the Gynecomastia and did I know what the next step was. I asked if it was I shave my beard and buy a dress! I then told him as far as I know it was AVS and removal or live with it. He made an endo referral!

>

> In the 6months he's been gone he gained alot of people skills. I thought we had a good appt. and he seemed to know about the ACCORD study and had an understanding where JNC8 is headed.

>

> - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with previous rt. flank pain. Treating with Meds. And DASH. . Current BP(last week ave): 131/76 HR 60

> Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and PTSD.

> Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg asprin, Metformin 2000MG and Spironolactone 50 MG.

>

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Share on other sites

Never heard of low salt diet causing low bicarbMay your pressure be low!CE Grim MS, MDSpecializing in DifficultHypertension

If cause of low blood CO2 is related to low salt as he was told seem like it would also be causeing Sx of low salt.

> > >

> > > Had a "Francis Experience" when tech wanted to take temp while taking BP! She started to head for my ear and I shook my head no. Continued and ran into hearing aid. Asked me to remove it and I shook head No again and held up 1 finger (index not middle). She got the message and waited!

> > >

> > > Saw Dr. K., the new Nepr. and you will never guess what his first question was: "So, have you got some BP charts for me?" Now there is a doctor that reviews the chart and obviously hasn't read the VA SOP manual! He thought he "could live with those numbers" and smiled when I asked if he thought I could!

> > >

> > > He then proceded to latest lab and said his only concern was my Carbon Dioxide numbers were going down (June 7=23, June 24=16, Oct 24=18 range=20 - 30). He drew a picture and blamed it on low sodium causing excess acid (blood bicarbonate level HC03). Said he wasn't making changes today but wanted me to be aware since he would be making recomendations for a new med if the trend continues. Guess I've got some researching to do!

> > >

> > > We talked about switching from Spiro to Epler and he saiid that would have to come from an Endo! Love the runaround! He cautioned me that it might not resolve the Gynecomastia and did I know what the next step was. I asked if it was I shave my beard and buy a dress! I then told him as far as I know it was AVS and removal or live with it. He made an endo referral!

> > >

> > > In the 6months he's been gone he gained alot of people skills. I thought we had a good appt. and he seemed to know about the ACCORD study and had an understanding where JNC8 is headed.

> > >

> > > - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with previous rt. flank pain. Treating with Meds. And DASH. . Current BP(last week ave): 131/76 HR 60

> > > Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and PTSD.

> > > Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg asprin, Metformin 2000MG and Spironolactone 50 MG.

> > >

> >

> >

>

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Share on other sites

Carbon dioxide (CO2) has always run 22 to 30 (range 20 - 30) from 2009 -

6/7/2011. Sodium during that period was 136 - 141 except for a 135 right at the

end of 2010 (range 135 - 145). Since then there have been two test: 6/24/11

CO2=16/NA=136 and 10/24/11 CO2=18/NA=135 hence Dr. K's concern/alert.

He didn't seem overly concerned at this point and elected to watch and warn me

that he may be making a recommendation which I could follow or not as I saw fit.

He did suggest it might be diet related and that I might be able to fix it thru

diet so I ordered a pizza and thought of ! NOT! He certainly didn't

imply that I wasn't in any immediate danger or should be hospitalized!

I am curious as to whether it could be a factor of diet since June is when I

changed my dietary habits. In fact that is the time period my PCP was trying to

add an ACEI so she had me on a 2week schedule for blood tests. Tests done 4/29,

5/12, 6/7 and 6/24. Results CO2/Na = 22/137, 24/138, 23/140 and 16/136.

This is almost as good as a good mystery! Stay tuned and I'll share clues as I

uncover them!

- 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with previous rt. flank

pain. Treating with Meds. And DASH. . Current BP(last week ave): 131/76 HR 60

Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and PTSD.

Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg asprin, Metformin

2000MG and Spironolactone 50 MG.

> >

> > Had a " Francis Experience " when tech wanted to take temp while taking BP!

She started to head for my ear and I shook my head no. Continued and ran into

hearing aid. Asked me to remove it and I shook head No again and held up 1

finger (index not middle). She got the message and waited!

> >

> > Saw Dr. K., the new Nepr. and you will never guess what his first question

was: " So, have you got some BP charts for me? " Now there is a doctor that

reviews the chart and obviously hasn't read the VA SOP manual! He thought he

" could live with those numbers " and smiled when I asked if he thought I could!

> >

> > He then proceded to latest lab and said his only concern was my Carbon

Dioxide numbers were going down (June 7=23, June 24=16, Oct 24=18 range=20 -

30). He drew a picture and blamed it on low sodium causing excess acid (blood

bicarbonate level HC03). Said he wasn't making changes today but wanted me to

be aware since he would be making recomendations for a new med if the trend

continues. Guess I've got some researching to do!

> >

> > We talked about switching from Spiro to Epler and he saiid that would have

to come from an Endo! Love the runaround! He cautioned me that it might not

resolve the Gynecomastia and did I know what the next step was. I asked if it

was I shave my beard and buy a dress! I then told him as far as I know it was

AVS and removal or live with it. He made an endo referral!

> >

> > In the 6months he's been gone he gained alot of people skills. I thought we

had a good appt. and he seemed to know about the ACCORD study and had an

understanding where JNC8 is headed.

> >

> > - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with previous rt.

flank pain. Treating with Meds. And DASH. . Current BP(last week ave): 131/76

HR 60

> > Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and PTSD.

> > Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg asprin,

Metformin 2000MG and Spironolactone 50 MG.

> >

>

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I don't believe it was an experience issue as much as a SOP for the VA issue!

Epler is nonformulary so only a privedged few can grant an exception, PCP

couldn't either even though it had been suggested by 3 different Neprologists.

The fact that it is not indicated for PA may also be an issue. He knew about

Epler and in fact talked a little about its narrower binding action and the fact

that it might not correct the Gynecomastia issue. I'm sure he could RX it if I

wanted to pay for it, I just don't know where I would have to go to fill it

since I don't know what state he's licensed in!

- 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with previous rt. flank

pain. Treating with Meds. And DASH. . Current BP(last week ave): 131/76 HR 60

Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and PTSD.

Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg asprin, Metformin

2000MG and Spironolactone 50 MG.

>

> > Had a " Francis Experience " when tech wanted to take temp while taking BP!

She started to head for my ear and I shook my head no. Continued and ran into

hearing aid. Asked me to remove it and I shook head No again and held up 1

finger (index not middle). She got the message and waited!

> >

> > Saw Dr. K., the new Nepr. and you will never guess what his first question

was: " So, have you got some BP charts for me? " Now there is a doctor that

reviews the chart and obviously hasn't read the VA SOP manual! He thought he

" could live with those numbers " and smiled when I asked if he thought I could!

> >

> > He then proceded to latest lab and said his only concern was my Carbon

Dioxide numbers were going down (June 7=23, June 24=16, Oct 24=18 range=20 -

30). He drew a picture and blamed it on low sodium causing excess acid (blood

bicarbonate level HC03). Said he wasn't making changes today but wanted me to be

aware since he would be making recomendations for a new med if the trend

continues. Guess I've got some researching to do!

> >

> > We talked about switching from Spiro to Epler and he saiid that would have

to come from an Endo! Love the runaround! He cautioned me that it might not

resolve the Gynecomastia and did I know what the next step was. I asked if it

was I shave my beard and buy a dress! I then told him as far as I know it was

AVS and removal or live with it. He made an endo referral!

> >

> > In the 6months he's been gone he gained alot of people skills. I thought we

had a good appt. and he seemed to know about the ACCORD study and had an

understanding where JNC8 is headed.

> >

> > - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with previous rt.

flank pain. Treating with Meds. And DASH. . Current BP(last week ave): 131/76 HR

60

> > Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and PTSD.

> > Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg asprin,

Metformin 2000MG and Spironolactone 50 MG.

> >

> >

>

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This is from the VA web site.

Aldosterone Antagonists (Eplerenone, Spironolactone)

Recommendations for Use in Heart Failure

January 2011

VA Pharmacy Benefits Management Services, Medical Advisory Panel, and VISN Pharmacist Executives

The following recommendations are based on medical evidence, clinician input, and expert opinion. The content of the document is dynamic and will be revised as new information becomes available. The purpose of this document is to assist practitioners in clinical decision-making, to standardize and improve the quality of patient care, and to promote cost-effective drug prescribing. The clinician should utilize this guidance and interpret it in the clinical context of the individual patient. The manufacturer's labeling should be consulted for detailed information when prescribing eplerenone or spironolactone.

Clinical Recommendations

An aldosterone antagonist (spironolactone is available on the VA National Formularya) is recommended in the management of systolic heart failure (HF)b in the following patients:

â–¡ Recent (within 6 months) New York Heart Association (NYHA) Class IV HF and current Class III or IV symptoms and left ventricular ejection fraction (LVEF) < 35% on standard therapy for HF, as indicated

Treatment with an aldosterone antagonist is recommended in addition to standard therapy (patients in the clinical trial included 95% on angiotensin-converting enzyme inhibitors [ACEI], 100% on loop diuretics, 75% on digoxin, 11% on a beta-blocker) in patients with moderately severe to severe HF to decrease mortality, decrease cardiovascular hospitalizations including hospitalizations for worsening HF, and to improve patient symptoms1,2

â–¡ Recent (within 6 months) cardiovascular hospitalization (or B-type natriuretic peptide [bNP] > 250 pg/ml or N-terminal pro-BNP > 500 pg/ml men or > 750 pg/ml women) and NYHA Class II HF with LVEF < 30% (or if > 30% to 35%, a QRS duration of > 130 msec on electrocardiogram) on standard therapy for HF, as indicated

More recently, data are available demonstrating that addition of an aldosterone antagonist to standard therapy (patients in the clinical trial included 78% on ACEIs, 19% on angiotensin II receptor antagonists, [93% ACEI, angiotensin II receptor antagonist, or both], 87% on a beta-blocker) in patients with mild HF symptoms reduces cardiovascular death or HF hospitalizations3

â–¡ LVEF < 40% early post-myocardial infarction (MI) with clinical evidence of HF

An aldosterone antagonist has also been recommended as therapy early after an acute MI in patients with left ventricular (LV) dysfunction and HF to reduce all-cause mortality, or cardiovascular death or hospitalization1,4

a Eplerenone is available via the nonformulary process. Eplerenone may be considered in a patient with intolerance to spironolactone (e.g., gynecomastia: 9% spironolactone2, 0.5% eplerenone4; breast pain: 2% spironolactone2, 0.8% eplerenone5). It should be noted that gynecomastia is potentially reversible with discontinuation of the medication if present for less than one year, but generally irreversible if present for over 1 year; providers should regularly question their patients about breast tenderness or enlargement while taking spironolactone and switch to eplerenone if this adverse events occurs

b It is unclear whether other patients with systolic failure/dysfunction (e.g., those with a LVEF 35-40%) will achieve similar benefit from an aldosterone antagonist; however, the data are suggestive, given the consistency of benefit from the clinical trials

Common, and potentially serious, adverse effects with the aldosterone antagonists include the development of hyperkalemia, especially in patients with impaired kidney function and/or who are receiving a potassium supplement or other medications with the potential to increase serum potassium (e.g., ACEIs, angiotensin II receptor antagonists, potassium-sparing diuretics). The risk vs. benefit of using an aldosterone antagonist, or modification of existing therapy to provide optimal patient outcomes while minimizing the potential for harm, in these patients needs to be determined on a case by case basis.

Monitoring of potassium and kidney function will vary depending on individual patient characteristics (refer to Note below); the following recommendations are per the respective prescribing information:

ü Eplerenone: measure potassium at baseline, within 1 week, and at 4 weeks after starting treatment, and periodically thereafter. Additional monitoring should be dictated by patient characteristics and potassium levels5

ü Spironolactone: measure potassium and creatinine 1 week after initiating therapy or dose increase, every 4 weeks for the first 3 months, every 3 months for 1 year, then every 6 months thereafter6

Note: initial monitoring earlier than 1 week (e.g., 3 days1) may be prudent, especially in patients at higher risk for developing hyperkalemia (e.g., baseline potassium > 4.2mEq/L, serum creatinine > 1.6 mg/dl, medications that may increase the risk for hyperkalemia, or with higher doses of an aldosterone antagonist,7 or in patients with conditions that may contribute to dehydration.1

Summary of Clinical Outcome Trials in HF

RALES

The recommendation to use an aldosterone antagonist in patients with moderately severe to severe HF is based on the Randomized Aldactone Evaluation Study (RALES), a clinical trial that enrolled 1663 patients with severe class IV HF within the last 6 months (and class III or IV at time of enrollment), a LVEF < 35% within the last 6 months, and treated with conventional therapy (95% ACEI, 100% loop diuretic, 75% digoxin). In addition, 11% of patients were on a beta-blocker. Patients were randomized to spironolactone 25 mg once daily or placebo, with the dose increased to 50 mg after 8 weeks only if the patients exhibited signs and symptoms of HF progression (mean dose 26 mg in the spironolactone treatment group), and if they were without hyperkalemia. The primary endpoint was to evaluate all-cause mortality. After a mean follow-up of 24 months, the trial was discontinued early due to a 30% reduction in death (34.6% spironolactone vs. 45.9% placebo) in patients treated with spironolactone. There was also a significant 35% decrease in hospitalizations due to worsening HF in patients on spironolactone; these patients also experienced significant improvement in HF symptoms.2

EMPHASIS-HF

More recently, the Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure (EMPHASIS-HF) was published that enrolled 2737 patients with NYHA class II HF symptoms, a LVEF < 30% (or if between 30% and up to 35%, with a QRS duration of > 130 msec on electrocardiogram), cardiovascular hospitalization within the past 6 months (or BNP > 250 pg/ml, or if plasma N-terminal pro-BNP was > 500 pg/ml in men or > 750 pg/ml in women), and on standard therapy for HF at optimal doses (78% ACEI, 19% angiotensin II receptor antagonist, [93% ACEI, angiotensin II receptor antagonist, or both], 87% beta-blocker). Patients were randomized to eplerenone 25 mg once daily or placebo, and were increased to 50 mg once daily after 4 weeks if the patient's serum potassium level was < 5.0 mmol/L. Of patients treated with eplerenone, 60.2% received the 50 mg dose; with a mean dose of 39.1+13.8 mg in all patients in the eplerenone treatment group. After a median follow-up of 21 months, the trial was discontinued early due to a predefined overwhelming benefit in the primary outcome of composite cardiovascular death or first HF hospitalization. Treatment with eplerenone reduced the risk of the primary endpoint by 37% compared to placebo (18.3% vs. 25.9%, respectively). All-cause mortality was significantly reduced by 24%, and HF hospitalizations by 42%, in patients treated with eplerenone.3

EPHESUS

The Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy Survival Study (EPHESUS) compared eplerenone (mean dose 42.6 mg per day) to placebo in 6642 patients within 3 to 14 days after acute MI complicated by LV dysfunction, and signs or symptoms of HF (patients with diabetes mellitus [DM] could be enrolled without having HF symptoms), with the majority on standard therapy for this indication. Ninety percent of patients had symptomatic HF. Treatment with eplerenone significantly reduced the primary endpoints of death from any cause (14.4% of patients on eplerenone vs. 16.7% of patients in the placebo group) and death from cardiovascular causes or first hospitalization for HF, recurrent acute MI, stroke, or ventricular arrhythmia (eplerenone 26.7% vs. placebo 30.0%).4

Safety Concerns

In addition to hyperkalemia, aldosterone antagonists may cause gynecomastia, gastrointestinal side effects, and menstrual irregularities. In RALES, gynecomastia or breast pain was reported in 10% of male patients in the spironolactone group. Although the incidence of serious hyperkalemia was not significantly different in patients treated with spironolactone compared to placebo in this trial, it is important to note that patients with serum creatinine > 2.5 mg/dL and serum potassium > 5.0 mEq/L were excluded, and patients were not taking other potassium-sparing diuretics unless hypokalemia developed.2 Serious hyperkalemia (> 6.0 mEq/L) occurred significantly more frequently with eplerenone compared to placebo in EPHESUS, and a potassium > 5.5 mEq/L was reported more frequently with eplerenone in EMPHASIS-HF; however, doses were titrated to 50 mg as part of the protocol of these trials. As in RALES, both EMPHASIS-HF and EPHESUS excluded patients with serum creatinine > 2.5 mg/dL (or estimated glomerular filtration rate [eGFR] < 30ml/min in EMPHASIS-HF), serum potassium > 5.0 mEq/L, or use of potassium-sparing diuretics.2-4 It is also important to note that patients were closely monitored as part of the clinical trial protocols. In clinical practice, reports of discontinuations due to hyperkalemia appear to be higher than seen in the clinical trials.8-12

An aldosterone antagonist should not be used in patients with the following:

· Uncorrected hyperkalemia (e.g., potassium > 5.0 mEq/L)

· Significant kidney impairment (e.g., serum creatinine > 2.5 mg/dLa or creatinine clearance < 30 mL/minb)

· Eplerenone should not be used in patients on concomitant therapy with a strong CYP 3A4 inhibitor (e.g., ketoconazole, itraconazole, nefazadone, clarithromycin, ritonavir, and nelfinavir)

a warning per product labeling for spironolactone based on RALES exclusion criteria

b contraindication per product labeling for eplerenone

Hyperkalemia with an aldosterone antagonist occurs more frequently in patients receiving potassium supplements and in patients with kidney impairment. Concomitant use of potassium supplements or potassium-sparing diuretics with an aldosterone antagonist should be avoided unless hypokalemia develops. In general, potassium supplements or potassium-sparing diuretics should be discontinued when therapy with an aldosterone antagonist is initiated. An aldosterone antagonist should also be used with caution in patients with a higher baseline potassium (e.g., > 4.2mEq/L), elevated serum creatinine (e.g., > 1.6 mg/dl), or receiving ACEIs7, angiotensin II receptor antagonists, or other medications that may increase the risk for hyperkalemia (e.g., cyclosporine, tacrolimus, nonsteroidal anti-inflammatory agents). Potassium should be monitored closely in these patients with follow-up evaluation of electrolytes and kidney function after initiation and dose adjustments. More frequent monitoring may be indicated in patients on concomitant medications that may contribute to increased potassium levels, with kidney impairment or DM, who are of advanced age, or experiencing worsening HF or conditions that may contribute to dehydration. In addition, patient education should be provided to avoid potassium salt substitutes, foods high in potassium, or the use of nonsteroidal anti-inflammatory agents, as indicated.

Dosing Recommendations

Spironolactone

Eplerenone

Initial Dose

25 mg once daily

(12.5 mg daily or 25 mg every other day

if Creatinine Clearance < 50 to 30 ml/min)1

25 mg once daily

Maximum Dose

Increase to 25 or 50 mg once daily,

as indicated in patients with worsening signs or

symptoms of HF and who do not have hyperkalemiaa

Titrate to 50 mg once daily,

as tolerated and in patients who do

not have hyperkalemiae

a serum potassium should be monitored carefully with dose increases

References

1. Hunt SA, Abraham WT, Chin MH, et al.; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, International Society for Heart and Lung Transplantation. 2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults. J Am Coll Cardiol published online Mar 26, 2009; doi:10.1016/j.jacc.2008.11.013

2. Pitt B, Zannad F, Remme WJ, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure: Randomized Aldactone Evaluation Study Investigators. N Engl J Med 1999;341:709-17.

3. Zannad F, McMurray JJV, Krum H, et al., for the EMPHASIS-HF Study Group. Eplerenone in patients with systolic heart failure with mild symptoms. N Engl J Med published online Nov 14, 2010; doi:10.1056/NEJMa1009492

4. Pitt B, Remme W, Zannad F, et al, for the Eplerenone Post-Myocardial Infarction Heart Failure Efficacy and Survival Study Investigators. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 2003;348:1309-21.

5. Inspra® (eplerenone) prescribing information. New York, NY: Pfizer, Inc.; 2008 Apr.

6. Aldactone® (spironolactone) prescribing information. New York, NY: Pfizer, Inc.; 2008 Jan.

7. The RALES Investigators. Effectiveness of spironolactone added to an angiotensin-converting enzyme inhibitor and a loop diuretic for severe chronic congestive heart failure (The Randomized Aldactone Evaluation Study [RALES]). Am J Cardiol 1996;78:902-7.

8. Tamirisa KP, son KD, Koelling TM. Spironolactone-induced renal insufficiency and hyperkalemia in patients with heart failure. Am Heart J 2004;148:971-8.

9. Sligl W, McAlister FA, Ezekowitz J, Armstrong PW. Usefulness of spironolactone in a specialized heart failure clinic. Am J Cardiol 2004;94:443-7.

10. Svensson M, Gustafsson F, Galatius S, Hildebrandt PR, Atar D. How prevalent is hyperkalemia and renal dysfunction during treatment with spironolactone in patients with congestive heart failure? J Card Fail 2004;10:297-303.

11. Bozkurt B, Agoston I, Knowlton AA. Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines. J Am Coll Cardiol 2003;41:211-4.

12. Juurlink DN, Mamdani MM, Lee DS, et al. Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. N Engl J Med 2004;351:543-51.

Prepared (November 2010)/Contact Person: Elaine M. Furmaga, Pharm.D, Clinical Pharmacy Specialist, VA National PBM Services

Trial

Eligibility Criteria

Treatment

Results

Safety

Conclusions

Quality

RALES2

1999

MC, R, DB, PC

U.S., Canada, Europe, Japan, Mexico, New Zealand, S. America, S. Africa

N=1663

Supported by Searle

Inclusion: NYHA class IV within 6 months and class III or IV at enrollment, HF dx > 6 wks, tx with ACEI and loop diuretic, LVEF < 35% within 6 months

Exclusion: Operable valvular heart disease, congenital heart disease, unstable angina, hepatic failure, cancer, other life-threatening disease, sCr > 2.5 mg/dL, K > 5.0 mmol/L

Spironolactone 25 mg once daily; dose increased to 50 mg once daily at 8 wks if signs or symptoms of HF progression without hyperkalemia (dose decreased to 25 mg every other day if hyperkalemia)

OR

Placebo

Duration: Mean 24 months (terminated early due to survival benefit)

Baseline: NYHA III (71%), IV (29%); mean EF (25%)

HF therapy: ACEI (95%), BB (11%), Digoxin (74%), Diuretics (100%)

Primary Endpoint

All-cause mortality: ¯ with spironolactone (RR 0.70 95% CI 0.60-0.82; ARR 11.4%; NNT=9)

Endpoint

Spironolactone (N=841)

Placebo

(N=822)

p value

Primary

284 (34.6%)

386 (45.9%)

<0.001

CV death

226 (27.5%)

314 (37.3%)

<0.001

HF hosp

215 (26.2%)

300 (35.7%)

<0.001

Mean dose: Spironolactone 26 mg once daily (31 mg in Placebo group)

DC Study Medication

Spironolactone (222, 26%), Placebo (211, 26%)

AE

Spironolactone

Placebo

> 1 AE

674 (82%)

667 (79%)

DC due to AE

62 (8%)

40 (5%)

Gynecomastia

55 (9%)a

8 (1%)

Breast pain

10 (2%)b

1 (0.1%)

Gynecomastia or breast pain

61 (10%)a

9 (1%)

Serious hyperkalemia

14 (2%)

10 (1%)

a in men; p<0.001 vs. placebo

b in men; p=0.006 vs. placebo

Spironolactone significantly reduced morbidity and mortality in patients with severe HF

Good

EMPHASIS- HF3

2010

MC, R, DB, PC

U.S., Canada, Europe, Asia, Australia, Mexico, S. America, S. Africa

N=2737

Supported by Pfizer

Inclusion: > 55yrs, NYHA class II, CV hosp in past 6 months (or BNP > 250pg/ml or pro-BNP > 500pg/ml men or > 750 pg/ml women), LVEF < 30% (or QRS > 130 msec if LVEF 31-35%), tx with ACEI or ARB, and BB

Exclusion: AMI, NYHA class III or IV HF, eGFR < 30ml/min/ 1.73m2 BSA, K > 5.0 mmol/L, K- sparing diuretic

Eplerenone 25 mg once daily X 4 wks; dose increased to 50 mg once daily

OR

Placebo

Duration: Median 21 months

Baseline: mean EF (26%); no CV hosp within 6 months (14%); mean K (4.3 mEq/L); mean sCr (1.1 mg/dl)

HF therapy: ACEI (78%), ARB (19%), ACEI, ARB, or both (93%), BB (87%)

Primary Endpoint

CV death or HF hosp: ¯ with eplerenone (HR 0.63 95% CI 0.54-0.74; ARR 7.7%; NNT=13)

Endpoint

Eplerenone (N=1364)

Placebo

(N=1373)

p value

Primary

249 (18.3%)

356 (25.9%)

<0.001

Death

171 (12.5%)

213 (15.5%)

0.008

CV death

147 (10.8%)

185 (13.5%)

0.01

HF hosp

164 (12.0%)

253 (18.4%)

<0.001

Mean dose: Eplerenone 39.1+13.8 mg once daily (40.8+12.9 mg in Placebo group)

DC Study Medication

Eplerenone (222, 16.3%), Placebo (228, 16.6%)

AE

Eplerenone

Placebo

All AE

979 (72%)

1007 (73.6%)

DC due to AE

188(13.8%)

222 (16.2%)

Hyperkalemia

109 (8%)a

50 (3.7%)

Hypokalemia

16 (1.2%)

30 (2.2%)

Gynecomastia or breast disorders

10 (0.7%)

14 (1%)

Kidney failure

26 (1.9%)

32 (2.3%)

a p<0.001 vs. placebo

Eplerenone significantly reduced risk for death and hospitalization in patients with systolic HF and mild symptoms

Good

EPHESUS4

2003

MC, R, DB, PC

U.S., Canada, Europe, Latin America

N=6632

Supported by Pharmacia

Inclusion

AMI (R within 3 to 14d), LVEF < 40% and

documented HF or DM, on optimal medical tx (e.g., ACEIs, ARBs, diuretics, BB, coronary perfusion tx)

Exclusion

Potassium-sparing diuretics, sCr > 2.5 mg/dL, K > 5.0 mmol/L

Eplerenone 25 mg once daily X 4 wks; dose increased to 50 mg once daily

OR

Placebo

Duration: Mean 16 months

Baseline: HF sx (90%); mean EF (33%); mean time from AMI to R (7d); mean K (4.3 mEq/L); mean sCr (1.1 mg/dl)

HF therapy: ACEI or ARB (87%), BB (75%), Diuretic (60%)

Primary Endpoints

Time to death (any cause): ¯ with eplerenone (RR 0.85 95% CI 0.75-0.96; ARR 2.3%; NNT 43)

Time to CV death or 1st CV hosp: ¯ with eplerenone (RR 0.87 95% CI 0.79-0.95; ARR 3.3%; NNT= 30)

Endpoint

Eplerenone (N=3319)

Placebo

(N=3313)

p value

Death

478 (14.4%)

554 (16.7%)

0.008

CV death or hosp

885 (26.7%)

993 (30.0%)

0.002

HF hosp

345 (10.4%)

391 (11.8%)

0.03

Mean dose: Eplerenone 43 mg once daily

DC Study Medication

Eplerenone (528, 16%), Placebo (493, 15%)

AE

Eplerenone

Placebo

> 1 AE

2608 (79%)

2623 (80%)

Gynecomastiaa

12 (0.5%)

14 (0.6%)

Serious hyperkalemia

180 (5.5%)b

126 (3.9%)

a in men

b p=0.002 vs. placebo

Eplerenone significantly reduced morbidity and mortality in patients with acute MI complicated by LVD and HF

Good

ACEI=angiotensin-converting enzyme inhibitor; AE=adverse event; AMI=acute myocardial infarction; ARB=angiotensin II receptor antagonist; ARR=absolute risk reduction; BB=beta-blockers; BNP=B-type natriuretic peptide; BSA=body surface area; CI=confidence interval; CV=cardiovascular; d=days; DB=double-blind; DC=discontinued; dx=diagnosis; EF=ejection fraction; HF=heart failure; hosp=hospitalizations; HR=hazard ratio; K=potassium; LVD=left ventricular dysfunction; LVEF=left ventricular ejection fraction; MI=myocardial infarction; N=number of patients; NYHA=New York Heart Association; NNT=number needed to treat; PC=placebo-controlled; R=randomized; RR=relative risk; sCr=serum creatinine; sx=symptoms; tx=treatment > > > > > Had a "Francis Experience" when tech wanted to take temp while taking BP! She started to head for my ear and I shook my head no. Continued and ran into hearing aid. Asked me to remove it and I shook head No again and held up 1 finger (index not middle). She got the message and waited!> > > > > > Saw Dr. K., the new Nepr. and you will never guess what his first question was: "So, have you got some BP charts for me?" Now there is a doctor that reviews the chart and obviously hasn't read the VA SOP manual! He thought he "could live with those numbers" and smiled when I asked if he thought I could!> > > > > > He then proceded to latest lab and said his only concern was my Carbon Dioxide numbers were going down (June 7=23, June 24=16, Oct 24=18 range=20 - 30). He drew a picture and blamed it on low sodium causing excess acid (blood bicarbonate level HC03). Said he wasn't making changes today but wanted me to be aware since he would be making recomendations for a new med if the trend continues. Guess I've got some researching to do!> > > > > > We talked about switching from Spiro to Epler and he saiid that would have to come from an Endo! Love the runaround! He cautioned me that it might not resolve the Gynecomastia and did I know what the next step was. I asked if it was I shave my beard and buy a dress! I then told him as far as I know it was AVS and removal or live with it. He made an endo referral!> > > > > > In the 6months he's been gone he gained alot of people skills. I thought we had a good appt. and he seemed to know about the ACCORD study and had an understanding where JNC8 is headed. > > > > > > - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with previous rt. flank pain. Treating with Meds. And DASH. . Current BP(last week ave): 131/76 HR 60> > > Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and PTSD.> > > Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg asprin, Metformin 2000MG and Spironolactone 50 MG. > > > > > >> >>

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Thanks Francis. I will sending an e-mail to Dr. Webster tonight explaining the

lack of success w/Neper and my desire to to proceed sooner rather than later

since " Man Boobs " are novel at first, the novelity soon wears off! Here is what

I copied out of your posting:

Aldosterone Antagonists (Eplerenone, Spironolactone)

Recommendations for Use in Heart Failure

January 2011

VA Pharmacy Benefits Management Services, Medical Advisory Panel, and VISN

Pharmacist Executives

The following recommendations are based on medical evidence, clinician input,

and expert opinion. The content of the document is dynamic and will be revised

as new information becomes available. The purpose of this document is to assist

practitioners in clinical decision-making, to standardize and improve the

quality of patient care, and to promote cost-effective drug prescribing. The

clinician should utilize this guidance and interpret it in the clinical context

of the individual patient. The manufacturer's labeling should be consulted for

detailed information when prescribing eplerenone or spironolactone.

Eplerenone is available via the nonformulary process. Eplerenone may be

considered in a patient with intolerance to spironolactone (e.g., gynecomastia:

9% spironolactone2, 0.5% eplerenone4; breast pain: 2% spironolactone2, 0.8%

eplerenone5). It should be noted that gynecomastia is potentially reversible

with discontinuation of the medication if present for less than one year, but

generally irreversible if present for over 1 year; providers should regularly

question their patients about breast tenderness or enlargement while taking

spironolactone and switch to eplerenone if this adverse events occurs

- 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with previous rt. flank

pain. Treating with Meds. And DASH. . Current BP(last week ave): 131/76 HR 60

Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and PTSD.

Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg asprin, Metformin

2000MG and Spironolactone 50 MG.

> > >

> > > > Had a " Francis Experience " when tech wanted to take temp while

> taking BP! She started to head for my ear and I shook my head no.

> Continued and ran into hearing aid. Asked me to remove it and I shook

> head No again and held up 1 finger (index not middle). She got the

> message and waited!

> > > >

> > > > Saw Dr. K., the new Nepr. and you will never guess what his first

> question was: " So, have you got some BP charts for me? " Now there is a

> doctor that reviews the chart and obviously hasn't read the VA SOP

> manual! He thought he " could live with those numbers " and smiled when I

> asked if he thought I could!

> > > >

> > > > He then proceded to latest lab and said his only concern was my

> Carbon Dioxide numbers were going down (June 7=23, June 24=16, Oct 24=18

> range=20 - 30). He drew a picture and blamed it on low sodium causing

> excess acid (blood bicarbonate level HC03). Said he wasn't making

> changes today but wanted me to be aware since he would be making

> recomendations for a new med if the trend continues. Guess I've got some

> researching to do!

> > > >

> > > > We talked about switching from Spiro to Epler and he saiid that

> would have to come from an Endo! Love the runaround! He cautioned me

> that it might not resolve the Gynecomastia and did I know what the next

> step was. I asked if it was I shave my beard and buy a dress! I then

> told him as far as I know it was AVS and removal or live with it. He

> made an endo referral!

> > > >

> > > > In the 6months he's been gone he gained alot of people skills. I

> thought we had a good appt. and he seemed to know about the ACCORD study

> and had an understanding where JNC8 is headed.

> > > >

> > > > - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with

> previous rt. flank pain. Treating with Meds. And DASH. . Current BP(last

> week ave): 131/76 HR 60

> > > > Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and

> PTSD.

> > > > Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg

> asprin, Metformin 2000MG and Spironolactone 50 MG.

> > > >

> > > >

> > >

> >

>

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Metformin does not? Natalia To: "hyperaldosteronism " <hyperaldosteronism >Sent: Saturday, November 5, 2011 2:44 PMSubject: Re: Re: Neperologist Appt. Update

Some diabetes meds. Some just have osmo receptor reset if been there for some time. May your pressure be low!CE Grim MS, MDSpecializing in DifficultHypertension

Which medications can cause low NA? I always have it low for last year. Now it's 129, and it's good for me. Natalia To: "hyperaldosteronism " <hyperaldosteronism >Sent: Saturday, November 5, 2011 11:42 AMSubject: Re: Re: Neperologist Appt. Update

No only if low Na causing Sx would adm be indicated and then if not sx rhe adjusting meds as possible causes had been stoppedMay your pressure be low!CE Grim MS, MDSpecializing in DifficultHypertension

What is your blood sodium ? If it is low than you have Hyponatremia and belive if this is the case The VA should have admitted you until NA returned to normal.

Hyponatremia — Comprehensive overview covers symptoms, causes and treatments of low blood sodium.

definition

Definition

Hyponatremia is a condition that occurs when the level of sodium in your blood is abnormally low.

Sodium is an electrolyte, and it helps regulate the amount of water that's in and around your cells. In hyponatremia, one or more factors — ranging from an underlying medical condition to drinking too much water during endurance sports — causes the sodium in your body to become diluted. When this happens, your body's water levels rise, and your cells begin to swell. This swelling can cause many health problems, from mild to severe.

Hyponatremia treatment is aimed at resolving the underlying condition. Depending on the cause of hyponatremia, you may simply need to cut back on how much you drink. In other cases of hyponatremia, you may need intravenous fluids and medications.

symptoms

Symptoms

Hyponatremia signs and symptoms may include:

Nausea and vomiting

Headache

Confusion

Loss of energy

Fatigue

Restlessness and irritability

Muscle weakness, spasms or cramps

Seizures

Unconsciousness

Coma

More likely you low blood CO2 is due to low K or low O2 not low sodium. You also must have a hyperventilation problem

Low carbon dioxide (CO2) in the body, or hypocapnia, causes blood to be less acidic. This condition is caused by hyperventilation, or excessive ventilation. It leads to a loss of carbon dioxide from the blood. It can be done on purpose, but mostly it is involuntary. CO2 is usually eliminated from the body rather quickly. The majority of it is transported through the blood as bicarbonate, only to be transformed back into CO2 once it has reached the lungs. This process helps to regulate the acid/alkaline balance in the body.

Read more: What Causes Low Co2 Levels? | eHow.com http://www.ehow.com/list_6688437_causes-low-co2-levels_.html#ixzz1cpYIFxLn

>

> Had a "Francis Experience" when tech wanted to take temp while taking BP! She started to head for my ear and I shook my head no. Continued and ran into hearing aid. Asked me to remove it and I shook head No again and held up 1 finger (index not middle). She got the message and waited!

>

> Saw Dr. K., the new Nepr. and you will never guess what his first question was: "So, have you got some BP charts for me?" Now there is a doctor that reviews the chart and obviously hasn't read the VA SOP manual! He thought he "could live with those numbers" and smiled when I asked if he thought I could!

>

> He then proceded to latest lab and said his only concern was my Carbon Dioxide numbers were going down (June 7=23, June 24=16, Oct 24=18 range=20 - 30). He drew a picture and blamed it on low sodium causing excess acid (blood bicarbonate level HC03). Said he wasn't making changes today but wanted me to be aware since he would be making recomendations for a new med if the trend continues. Guess I've got some researching to do!

>

> We talked about switching from Spiro to Epler and he saiid that would have to come from an Endo! Love the runaround! He cautioned me that it might not resolve the Gynecomastia and did I know what the next step was. I asked if it was I shave my beard and buy a dress! I then told him as far as I know it was AVS and removal or live with it. He made an endo referral!

>

> In the 6months he's been gone he gained alot of people skills. I thought we had a good appt. and he seemed to know about the ACCORD study and had an understanding where JNC8 is headed.

>

> - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with previous rt. flank pain. Treating with Meds. And DASH. . Current BP(last week ave): 131/76 HR 60

> Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and PTSD.

> Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg asprin, Metformin 2000MG and Spironolactone 50 MG.

>

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Has your Na ever been "nomral"> Carbon dioxide (CO2) has always run 22 to 30 (range 20 - 30) from 2009 - 6/7/2011. Sodium during that period was 136 - 141 except for a 135 right at the end of 2010 (range 135 - 145). Since then there have been two test: 6/24/11 CO2=16/NA=136 and 10/24/11 CO2=18/NA=135 hence Dr. K's concern/alert. He didn't seem overly concerned at this point and elected to watch and warn me that he may be making a recommendation which I could follow or not as I saw fit. He did suggest it might be diet related and that I might be able to fix it thru diet so I ordered a pizza and thought of ! NOT! He certainly didn't imply that I wasn't in any immediate danger or should be hospitalized! I am curious as to whether it could be a factor of diet since June is when I changed my dietary habits. In fact that is the time period my PCP was trying to add an ACEI so she had me on a 2week schedule for blood tests. Tests done 4/29, 5/12, 6/7 and 6/24. Results CO2/Na = 22/137, 24/138, 23/140 and 16/136. This is almost as good as a good mystery! Stay tuned and I'll share clues as I uncover them! - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with previous rt. flank pain. Treating with Meds. And DASH. . Current BP(last week ave): 131/76 HR 60 Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and PTSD. Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg asprin, Metformin 2000MG and Spironolactone 50 MG. > > > > Had a "Francis Experience" when tech wanted to take temp while taking BP! She started to head for my ear and I shook my head no. Continued and ran into hearing aid. Asked me to remove it and I shook head No again and held up 1 finger (index not middle). She got the message and waited! > > > > Saw Dr. K., the new Nepr. and you will never guess what his first question was: "So, have you got some BP charts for me?" Now there is a doctor that reviews the chart and obviously hasn't read the VA SOP manual! He thought he "could live with those numbers" and smiled when I asked if he thought I could! > > > > He then proceded to latest lab and said his only concern was my Carbon Dioxide numbers were going down (June 7=23, June 24=16, Oct 24=18 range=20 - 30). He drew a picture and blamed it on low sodium causing excess acid (blood bicarbonate level HC03). Said he wasn't making changes today but wanted me to be aware since he would be making recomendations for a new med if the trend continues. Guess I've got some researching to do! > > > > We talked about switching from Spiro to Epler and he saiid that would have to come from an Endo! Love the runaround! He cautioned me that it might not resolve the Gynecomastia and did I know what the next step was. I asked if it was I shave my beard and buy a dress! I then told him as far as I know it was AVS and removal or live with it. He made an endo referral! > > > > In the 6months he's been gone he gained alot of people skills. I thought we had a good appt. and he seemed to know about the ACCORD study and had an understanding where JNC8 is headed. > > > > - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with previous rt. flank pain. Treating with Meds. And DASH. . Current BP(last week ave): 131/76 HR 60 > > Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and PTSD. > > Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg asprin, Metformin 2000MG and Spironolactone 50 MG. > > >

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This is interesting as eplerenone is also approved for use in HTN but not used much by VA. Also note the much lower dose than is needed in PA.CE Grim MD This is from the VA web site. Aldosterone Antagonists (Eplerenone, Spironolactone) Recommendations for Use in Heart Failure January 2011 VA Pharmacy Benefits Management Services, Medical Advisory Panel, and VISN Pharmacist ExecutivesThe following recommendations are based on medical evidence, clinician input, and expert opinion. The content of the document is dynamic and will be revised as new information becomes available. The purpose of this document is to assist practitioners in clinical decision-making, to standardize and improve the quality of patient care, and to promote cost-effective drug prescribing. The clinician should utilize this guidance and interpret it in the clinical context of the individual patient. The manufacturer's labeling should be consulted for detailed information when prescribing eplerenone or spironolactone. Clinical Recommendations An aldosterone antagonist (spironolactone is available on the VA National Formularya) is recommended in the management of systolic heart failure (HF)b in the following patients: â–¡ Recent (within 6 months) New York Heart Association (NYHA) Class IV HF and current Class III or IV symptoms and left ventricular ejection fraction (LVEF) < 35% on standard therapy for HF, as indicated Treatment with an aldosterone antagonist is recommended in addition to standard therapy (patients in the clinical trial included 95% on angiotensin-converting enzyme inhibitors [ACEI], 100% on loop diuretics, 75% on digoxin, 11% on a beta-blocker) in patients with moderately severe to severe HF to decrease mortality, decrease cardiovascular hospitalizations including hospitalizations for worsening HF, and to improve patient symptoms1,2 â–¡ Recent (within 6 months) cardiovascular hospitalization (or B-type natriuretic peptide [bNP] > 250 pg/ml or N-terminal pro-BNP > 500 pg/ml men or > 750 pg/ml women) and NYHA Class II HF with LVEF < 30% (or if > 30% to 35%, a QRS duration of > 130 msec on electrocardiogram) on standard therapy for HF, as indicated More recently, data are available demonstrating that addition of an aldosterone antagonist to standard therapy (patients in the clinical trial included 78% on ACEIs, 19% on angiotensin II receptor antagonists, [93% ACEI, angiotensin II receptor antagonist, or both], 87% on a beta-blocker) in patients with mild HF symptoms reduces cardiovascular death or HF hospitalizations3 â–¡ LVEF < 40% early post-myocardial infarction (MI) with clinical evidence of HFAn aldosterone antagonist has also been recommended as therapy early after an acute MI in patients with left ventricular (LV) dysfunction and HF to reduce all-cause mortality, or cardiovascular death or hospitalization1,4 a Eplerenone is available via the nonformulary process. Eplerenone may be considered in a patient with intolerance to spironolactone (e.g., gynecomastia: 9% spironolactone2, 0.5% eplerenone4; breast pain: 2% spironolactone2, 0.8% eplerenone5). It should be noted that gynecomastia is potentially reversible with discontinuation of the medication if present for less than one year, but generally irreversible if present for over 1 year; providers should regularly question their patients about breast tenderness or enlargement while taking spironolactone and switch to eplerenone if this adverse events occursb It is unclear whether other patients with systolic failure/dysfunction (e.g., those with a LVEF 35-40%) will achieve similar benefit from an aldosterone antagonist; however, the data are suggestive, given the consistency of benefit from the clinical trials Common, and potentially serious, adverse effects with the aldosterone antagonists include the development of hyperkalemia, especially in patients with impaired kidney function and/or who are receiving a potassium supplement or other medications with the potential to increase serum potassium (e.g., ACEIs, angiotensin II receptor antagonists, potassium-sparing diuretics). The risk vs. benefit of using an aldosterone antagonist, or modification of existing therapy to provide optimal patient outcomes while minimizing the potential for harm, in these patients needs to be determined on a case by case basis. Monitoring of potassium and kidney function will vary depending on individual patient characteristics (refer to Note below); the following recommendations are per the respective prescribing information:ü Eplerenone: measure potassium at baseline, within 1 week, and at 4 weeks after starting treatment, and periodically thereafter. Additional monitoring should be dictated by patient characteristics and potassium levels5ü Spironolactone: measure potassium and creatinine 1 week after initiating therapy or dose increase, every 4 weeks for the first 3 months, every 3 months for 1 year, then every 6 months thereafter6 Note: initial monitoring earlier than 1 week (e.g., 3 days1) may be prudent, especially in patients at higher risk for developing hyperkalemia (e.g., baseline potassium > 4.2mEq/L, serum creatinine > 1.6 mg/dl, medications that may increase the risk for hyperkalemia, or with higher doses of an aldosterone antagonist,7 or in patients with conditions that may contribute to dehydration.1Summary of Clinical Outcome Trials in HF RALES The recommendation to use an aldosterone antagonist in patients with moderately severe to severe HF is based on the Randomized Aldactone Evaluation Study (RALES), a clinical trial that enrolled 1663 patients with severe class IV HF within the last 6 months (and class III or IV at time of enrollment), a LVEF < 35% within the last 6 months, and treated with conventional therapy (95% ACEI, 100% loop diuretic, 75% digoxin). In addition, 11% of patients were on a beta-blocker. Patients were randomized to spironolactone 25 mg once daily or placebo, with the dose increased to 50 mg after 8 weeks only if the patients exhibited signs and symptoms of HF progression (mean dose 26 mg in the spironolactone treatment group), and if they were without hyperkalemia. The primary endpoint was to evaluate all-cause mortality. After a mean follow-up of 24 months, the trial was discontinued early due to a 30% reduction in death (34.6% spironolactone vs. 45.9% placebo) in patients treated with spironolactone. There was also a significant 35% decrease in hospitalizations due to worsening HF in patients on spironolactone; these patients also experienced significant improvement in HF symptoms.2 EMPHASIS-HF More recently, the Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure (EMPHASIS-HF) was published that enrolled 2737 patients with NYHA class II HF symptoms, a LVEF < 30% (or if between 30% and up to 35%, with a QRS duration of > 130 msec on electrocardiogram), cardiovascular hospitalization within the past 6 months (or BNP > 250 pg/ml, or if plasma N-terminal pro-BNP was > 500 pg/ml in men or > 750 pg/ml in women), and on standard therapy for HF at optimal doses (78% ACEI, 19% angiotensin II receptor antagonist, [93% ACEI, angiotensin II receptor antagonist, or both], 87% beta-blocker). Patients were randomized to eplerenone 25 mg once daily or placebo, and were increased to 50 mg once daily after 4 weeks if the patient's serum potassium level was < 5.0 mmol/L. Of patients treated with eplerenone, 60.2% received the 50 mg dose; with a mean dose of 39.1+13.8 mg in all patients in the eplerenone treatment group. After a median follow-up of 21 months, the trial was discontinued early due to a predefined overwhelming benefit in the primary outcome of composite cardiovascular death or first HF hospitalization. Treatment with eplerenone reduced the risk of the primary endpoint by 37% compared to placebo (18.3% vs. 25.9%, respectively). All-cause mortality was significantly reduced by 24%, and HF hospitalizations by 42%, in patients treated with eplerenone.3 EPHESUS The Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy Survival Study (EPHESUS) compared eplerenone (mean dose 42.6 mg per day) to placebo in 6642 patients within 3 to 14 days after acute MI complicated by LV dysfunction, and signs or symptoms of HF (patients with diabetes mellitus [DM] could be enrolled without having HF symptoms), with the majority on standard therapy for this indication. Ninety percent of patients had symptomatic HF. Treatment with eplerenone significantly reduced the primary endpoints of death from any cause (14.4% of patients on eplerenone vs. 16.7% of patients in the placebo group) and death from cardiovascular causes or first hospitalization for HF, recurrent acute MI, stroke, or ventricular arrhythmia (eplerenone 26.7% vs. placebo 30.0%).4 Safety Concerns In addition to hyperkalemia, aldosterone antagonists may cause gynecomastia, gastrointestinal side effects, and menstrual irregularities. In RALES, gynecomastia or breast pain was reported in 10% of male patients in the spironolactone group. Although the incidence of serious hyperkalemia was not significantly different in patients treated with spironolactone compared to placebo in this trial, it is important to note that patients with serum creatinine > 2.5 mg/dL and serum potassium > 5.0 mEq/L were excluded, and patients were not taking other potassium-sparing diuretics unless hypokalemia developed.2 Serious hyperkalemia (> 6.0 mEq/L) occurred significantly more frequently with eplerenone compared to placebo in EPHESUS, and a potassium > 5.5 mEq/L was reported more frequently with eplerenone in EMPHASIS-HF; however, doses were titrated to 50 mg as part of the protocol of these trials. As in RALES, both EMPHASIS-HF and EPHESUS excluded patients with serum creatinine > 2.5 mg/dL (or estimated glomerular filtration rate [eGFR] < 30ml/min in EMPHASIS-HF), serum potassium > 5.0 mEq/L, or use of potassium-sparing diuretics.2-4 It is also important to note that patients were closely monitored as part of the clinical trial protocols. In clinical practice, reports of discontinuations due to hyperkalemia appear to be higher than seen in the clinical trials.8-12 An aldosterone antagonist should not be used in patients with the following: · Uncorrected hyperkalemia (e.g., potassium > 5.0 mEq/L)· Significant kidney impairment (e.g., serum creatinine > 2.5 mg/dLa or creatinine clearance < 30 mL/minb)· Eplerenone should not be used in patients on concomitant therapy with a strong CYP 3A4 inhibitor (e.g., ketoconazole, itraconazole, nefazadone, clarithromycin, ritonavir, and nelfinavir)a warning per product labeling for spironolactone based on RALES exclusion criteriab contraindication per product labeling for eplerenone Hyperkalemia with an aldosterone antagonist occurs more frequently in patients receiving potassium supplements and in patients with kidney impairment. Concomitant use of potassium supplements or potassium-sparing diuretics with an aldosterone antagonist should be avoided unless hypokalemia develops. In general, potassium supplements or potassium-sparing diuretics should be discontinued when therapy with an aldosterone antagonist is initiated. An aldosterone antagonist should also be used with caution in patients with a higher baseline potassium (e.g., > 4.2mEq/L), elevated serum creatinine (e.g., > 1.6 mg/dl), or receiving ACEIs7, angiotensin II receptor antagonists, or other medications that may increase the risk for hyperkalemia (e.g., cyclosporine, tacrolimus, nonsteroidal anti-inflammatory agents). Potassium should be monitored closely in these patients with follow-up evaluation of electrolytes and kidney function after initiation and dose adjustments. More frequent monitoring may be indicated in patients on concomitant medications that may contribute to increased potassium levels, with kidney impairment or DM, who are of advanced age, or experiencing worsening HF or conditions that may contribute to dehydration. In addition, patient education should be provided to avoid potassium salt substitutes, foods high in potassium, or the use of nonsteroidal anti-inflammatory agents, as indicated. Dosing Recommendations Spironolactone Eplerenone Initial Dose 25 mg once daily(12.5 mg daily or 25 mg every other dayif Creatinine Clearance < 50 to 30 ml/min)1 25 mg once daily Maximum Dose Increase to 25 or 50 mg once daily, as indicated in patients with worsening signs or symptoms of HF and who do not have hyperkalemiaa Titrate to 50 mg once daily,as tolerated and in patients who do not have hyperkalemiaea serum potassium should be monitored carefully with dose increases References 1. Hunt SA, Abraham WT, Chin MH, et al.; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, International Society for Heart and Lung Transplantation. 2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults. J Am Coll Cardiol published online Mar 26, 2009; doi:10.1016/j.jacc.2008.11.0132. Pitt B, Zannad F, Remme WJ, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure: Randomized Aldactone Evaluation Study Investigators. N Engl J Med 1999;341:709-17.3. Zannad F, McMurray JJV, Krum H, et al., for the EMPHASIS-HF Study Group. Eplerenone in patients with systolic heart failure with mild symptoms. N Engl J Med published online Nov 14, 2010; doi:10.1056/NEJMa10094924. Pitt B, Remme W, Zannad F, et al, for the Eplerenone Post-Myocardial Infarction Heart Failure Efficacy and Survival Study Investigators. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 2003;348:1309-21.5. Inspra® (eplerenone) prescribing information. New York, NY: Pfizer, Inc.; 2008 Apr.6. Aldactone® (spironolactone) prescribing information. New York, NY: Pfizer, Inc.; 2008 Jan.7. The RALES Investigators. Effectiveness of spironolactone added to an angiotensin-converting enzyme inhibitor and a loop diuretic for severe chronic congestive heart failure (The Randomized Aldactone Evaluation Study [RALES]). Am J Cardiol 1996;78:902-7. 8. Tamirisa KP, son KD, Koelling TM. Spironolactone-induced renal insufficiency and hyperkalemia in patients with heart failure. Am Heart J 2004;148:971-8.9. Sligl W, McAlister FA, Ezekowitz J, Armstrong PW. Usefulness of spironolactone in a specialized heart failure clinic. Am J Cardiol 2004;94:443-7.10. Svensson M, Gustafsson F, Galatius S, Hildebrandt PR, Atar D. How prevalent is hyperkalemia and renal dysfunction during treatment with spironolactone in patients with congestive heart failure? J Card Fail 2004;10:297-303.11. Bozkurt B, Agoston I, Knowlton AA. Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines. J Am Coll Cardiol 2003;41:211-4.12. Juurlink DN, Mamdani MM, Lee DS, et al. Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. N Engl J Med 2004;351:543-51. Prepared (November 2010)/Contact Person: Elaine M. Furmaga, Pharm.D, Clinical Pharmacy Specialist, VA National PBM Services Trial Eligibility Criteria Treatment Results Safety Conclusions Quality RALES21999MC, R, DB, PC U.S., Canada, Europe, Japan, Mexico, New Zealand, S. America, S. Africa N=1663 Supported by Searle Inclusion: NYHA class IV within 6 months and class III or IV at enrollment, HF dx > 6 wks, tx with ACEI and loop diuretic, LVEF < 35% within 6 months Exclusion: Operable valvular heart disease, congenital heart disease, unstable angina, hepatic failure, cancer, other life-threatening disease, sCr > 2.5 mg/dL, K > 5.0 mmol/L Spironolactone 25 mg once daily; dose increased to 50 mg once daily at 8 wks if signs or symptoms of HF progression without hyperkalemia (dose decreased to 25 mg every other day if hyperkalemia)ORPlacebo Duration: Mean 24 months (terminated early due to survival benefit) Baseline: NYHA III (71%), IV (29%); mean EF (25%) HF therapy: ACEI (95%), BB (11%), Digoxin (74%), Diuretics (100%) Primary EndpointAll-cause mortality: ¯ with spironolactone (RR 0.70 95% CI 0.60-0.82; ARR 11.4%; NNT=9) Endpoint Spironolactone (N=841) Placebo(N=822) p value Primary 284 (34.6%) 386 (45.9%) <0.001 CV death 226 (27.5%) 314 (37.3%) <0.001 HF hosp 215 (26.2%) 300 (35.7%) <0.001 Mean dose: Spironolactone 26 mg once daily (31 mg in Placebo group) DC Study MedicationSpironolactone (222, 26%), Placebo (211, 26%) AE Spironolactone Placebo > 1 AE 674 (82%) 667 (79%) DC due to AE 62 (8%) 40 (5%) Gynecomastia 55 (9%)a 8 (1%) Breast pain 10 (2%)b 1 (0.1%) Gynecomastia or breast pain 61 (10%)a 9 (1%) Serious hyperkalemia 14 (2%) 10 (1%)a in men; p<0.001 vs. placebob in men; p=0.006 vs. placebo Spironolactone significantly reduced morbidity and mortality in patients with severe HF Good EMPHASIS- HF32010MC, R, DB, PC U.S., Canada, Europe, Asia, Australia, Mexico, S. America, S. Africa N=2737 Supported by Pfizer Inclusion: > 55yrs, NYHA class II, CV hosp in past 6 months (or BNP > 250pg/ml or pro-BNP > 500pg/ml men or > 750 pg/ml women), LVEF < 30% (or QRS > 130 msec if LVEF 31-35%), tx with ACEI or ARB, and BB Exclusion: AMI, NYHA class III or IV HF, eGFR < 30ml/min/ 1.73m2 BSA, K > 5.0 mmol/L, K- sparing diuretic Eplerenone 25 mg once daily X 4 wks; dose increased to 50 mg once dailyORPlacebo Duration: Median 21 months Baseline: mean EF (26%); no CV hosp within 6 months (14%); mean K (4.3 mEq/L); mean sCr (1.1 mg/dl) HF therapy: ACEI (78%), ARB (19%), ACEI, ARB, or both (93%), BB (87%) Primary EndpointCV death or HF hosp: ¯ with eplerenone (HR 0.63 95% CI 0.54-0.74; ARR 7.7%; NNT=13) Endpoint Eplerenone (N=1364) Placebo(N=1373) p value Primary 249 (18.3%) 356 (25.9%) <0.001 Death 171 (12.5%) 213 (15.5%) 0.008 CV death 147 (10.8%) 185 (13.5%) 0.01 HF hosp 164 (12.0%) 253 (18.4%) <0.001 Mean dose: Eplerenone 39.1+13.8 mg once daily (40.8+12.9 mg in Placebo group) DC Study MedicationEplerenone (222, 16.3%), Placebo (228, 16.6%) AE Eplerenone Placebo All AE 979 (72%) 1007 (73.6%) DC due to AE 188(13.8%) 222 (16.2%) Hyperkalemia 109 (8%)a 50 (3.7%) Hypokalemia 16 (1.2%) 30 (2.2%) Gynecomastia or breast disorders 10 (0.7%) 14 (1%) Kidney failure 26 (1.9%) 32 (2.3%)a p<0.001 vs. placebo Eplerenone significantly reduced risk for death and hospitalization in patients with systolic HF and mild symptoms Good EPHESUS42003MC, R, DB, PC U.S., Canada, Europe, Latin America N=6632 Supported by Pharmacia InclusionAMI (R within 3 to 14d), LVEF < 40% and documented HF or DM, on optimal medical tx (e.g., ACEIs, ARBs, diuretics, BB, coronary perfusion tx) ExclusionPotassium-sparing diuretics, sCr > 2.5 mg/dL, K > 5.0 mmol/L Eplerenone 25 mg once daily X 4 wks; dose increased to 50 mg once dailyORPlacebo Duration: Mean 16 months Baseline: HF sx (90%); mean EF (33%); mean time from AMI to R (7d); mean K (4.3 mEq/L); mean sCr (1.1 mg/dl)HF therapy: ACEI or ARB (87%), BB (75%), Diuretic (60%) Primary EndpointsTime to death (any cause): ¯ with eplerenone (RR 0.85 95% CI 0.75-0.96; ARR 2.3%; NNT 43)Time to CV death or 1st CV hosp: ¯ with eplerenone (RR 0.87 95% CI 0.79-0.95; ARR 3.3%; NNT= 30) Endpoint Eplerenone (N=3319) Placebo(N=3313) p value Death 478 (14.4%) 554 (16.7%) 0.008 CV death or hosp 885 (26.7%) 993 (30.0%) 0.002 HF hosp 345 (10.4%) 391 (11.8%) 0.03 Mean dose: Eplerenone 43 mg once daily DC Study MedicationEplerenone (528, 16%), Placebo (493, 15%) AE Eplerenone Placebo > 1 AE 2608 (79%) 2623 (80%) Gynecomastiaa 12 (0.5%) 14 (0.6%) Serious hyperkalemia 180 (5.5%)b 126 (3.9%)a in men b p=0.002 vs. placebo Eplerenone significantly reduced morbidity and mortality in patients with acute MI complicated by LVD and HF GoodACEI=angiotensin-converting enzyme inhibitor; AE=adverse event; AMI=acute myocardial infarction; ARB=angiotensin II receptor antagonist; ARR=absolute risk reduction; BB=beta-blockers; BNP=B-type natriuretic peptide; BSA=body surface area; CI=confidence interval; CV=cardiovascular; d=days; DB=double-blind; DC=discontinued; dx=diagnosis; EF=ejection fraction; HF=heart failure; hosp=hospitalizations; HR=hazard ratio; K=potassium; LVD=left ventricular dysfunction; LVEF=left ventricular ejection fraction; MI=myocardial infarction; N=number of patients; NYHA=New York Heart Association; NNT=number needed to treat; PC=placebo-controlled; R=randomized; RR=relative risk; sCr=serum creatinine; sx=symptoms; tx=treatment > > > > > Had a "Francis Experience" when tech wanted to take temp while taking BP! She started to head for my ear and I shook my head no. Continued and ran into hearing aid. Asked me to remove it and I shook head No again and held up 1 finger (index not middle). She got the message and waited!> > > > > > Saw Dr. K., the new Nepr. and you will never guess what his first question was: "So, have you got some BP charts for me?" Now there is a doctor that reviews the chart and obviously hasn't read the VA SOP manual! He thought he "could live with those numbers" and smiled when I asked if he thought I could!> > > > > > He then proceded to latest lab and said his only concern was my Carbon Dioxide numbers were going down (June 7=23, June 24=16, Oct 24=18 range=20 - 30). He drew a picture and blamed it on low sodium causing excess acid (blood bicarbonate level HC03). Said he wasn't making changes today but wanted me to be aware since he would be making recomendations for a new med if the trend continues. Guess I've got some researching to do!> > > > > > We talked about switching from Spiro to Epler and he saiid that would have to come from an Endo! Love the runaround! He cautioned me that it might not resolve the Gynecomastia and did I know what the next step was. I asked if it was I shave my beard and buy a dress! I then told him as far as I know it was AVS and removal or live with it. He made an endo referral!> > > > > > In the 6months he's been gone he gained alot of people skills. I thought we had a good appt. and he seemed to know about the ACCORD study and had an understanding where JNC8 is headed. > > > > > > - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with previous rt. flank pain. Treating with Meds. And DASH. . Current BP(last week ave): 131/76 HR 60> > > Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and PTSD.> > > Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg asprin, Metformin 2000MG and Spironolactone 50 MG. > > > > > >> >>

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I do not know where the 1 year non-reversibility of gynecomastia comes from. Maybe someone can find out.CE Grim MD Thanks Francis. I will sending an e-mail to Dr. Webster tonight explaining the lack of success w/Neper and my desire to to proceed sooner rather than later since "Man Boobs" are novel at first, the novelity soon wears off! Here is what I copied out of your posting: Aldosterone Antagonists (Eplerenone, Spironolactone) Recommendations for Use in Heart Failure January 2011 VA Pharmacy Benefits Management Services, Medical Advisory Panel, and VISN Pharmacist Executives The following recommendations are based on medical evidence, clinician input, and expert opinion. The content of the document is dynamic and will be revised as new information becomes available. The purpose of this document is to assist practitioners in clinical decision-making, to standardize and improve the quality of patient care, and to promote cost-effective drug prescribing. The clinician should utilize this guidance and interpret it in the clinical context of the individual patient. The manufacturer's labeling should be consulted for detailed information when prescribing eplerenone or spironolactone. Eplerenone is available via the nonformulary process. Eplerenone may be considered in a patient with intolerance to spironolactone (e.g., gynecomastia: 9% spironolactone2, 0.5% eplerenone4; breast pain: 2% spironolactone2, 0.8% eplerenone5). It should be noted that gynecomastia is potentially reversible with discontinuation of the medication if present for less than one year, but generally irreversible if present for over 1 year; providers should regularly question their patients about breast tenderness or enlargement while taking spironolactone and switch to eplerenone if this adverse events occurs - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with previous rt. flank pain. Treating with Meds. And DASH. . Current BP(last week ave): 131/76 HR 60 Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and PTSD. Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg asprin, Metformin 2000MG and Spironolactone 50 MG. > > > > > > > Had a "Francis Experience" when tech wanted to take temp while > taking BP! She started to head for my ear and I shook my head no. > Continued and ran into hearing aid. Asked me to remove it and I shook > head No again and held up 1 finger (index not middle). She got the > message and waited! > > > > > > > > Saw Dr. K., the new Nepr. and you will never guess what his first > question was: "So, have you got some BP charts for me?" Now there is a > doctor that reviews the chart and obviously hasn't read the VA SOP > manual! He thought he "could live with those numbers" and smiled when I > asked if he thought I could! > > > > > > > > He then proceded to latest lab and said his only concern was my > Carbon Dioxide numbers were going down (June 7=23, June 24=16, Oct 24=18 > range=20 - 30). He drew a picture and blamed it on low sodium causing > excess acid (blood bicarbonate level HC03). Said he wasn't making > changes today but wanted me to be aware since he would be making > recomendations for a new med if the trend continues. Guess I've got some > researching to do! > > > > > > > > We talked about switching from Spiro to Epler and he saiid that > would have to come from an Endo! Love the runaround! He cautioned me > that it might not resolve the Gynecomastia and did I know what the next > step was. I asked if it was I shave my beard and buy a dress! I then > told him as far as I know it was AVS and removal or live with it. He > made an endo referral! > > > > > > > > In the 6months he's been gone he gained alot of people skills. I > thought we had a good appt. and he seemed to know about the ACCORD study > and had an understanding where JNC8 is headed. > > > > > > > > - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with > previous rt. flank pain. Treating with Meds. And DASH. . Current BP(last > week ave): 131/76 HR 60 > > > > Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and > PTSD. > > > > Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg > asprin, Metformin 2000MG and Spironolactone 50 MG. > > > > > > > > > > > > > >

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metformin does.CE Grim MD Metformin does not? Natalia To: "hyperaldosteronism " <hyperaldosteronism >Sent: Saturday, November 5, 2011 2:44 PMSubject: Re: Re: Neperologist Appt. Update Some diabetes meds. Some just have osmo receptor reset if been there for some time. May your pressure be low!CE Grim MS, MDSpecializing in DifficultHypertension Which medications can cause low NA? I always have it low for last year. Now it's 129, and it's good for me. Natalia To: "hyperaldosteronism " <hyperaldosteronism >Sent: Saturday, November 5, 2011 11:42 AMSubject: Re: Re: Neperologist Appt. Update No only if low Na causing Sx would adm be indicated and then if not sx rhe adjusting meds as possible causes had been stoppedMay your pressure be low!CE Grim MS, MDSpecializing in DifficultHypertension What is your blood sodium ? If it is low than you have Hyponatremia and belive if this is the case The VA should have admitted you until NA returned to normal. Hyponatremia — Comprehensive overview covers symptoms, causes and treatments of low blood sodium. definition Definition Hyponatremia is a condition that occurs when the level of sodium in your blood is abnormally low. Sodium is an electrolyte, and it helps regulate the amount of water that's in and around your cells. In hyponatremia, one or more factors — ranging from an underlying medical condition to drinking too much water during endurance sports — causes the sodium in your body to become diluted. When this happens, your body's water levels rise, and your cells begin to swell. This swelling can cause many health problems, from mild to severe. Hyponatremia treatment is aimed at resolving the underlying condition. Depending on the cause of hyponatremia, you may simply need to cut back on how much you drink. In other cases of hyponatremia, you may need intravenous fluids and medications. symptoms Symptoms Hyponatremia signs and symptoms may include: Nausea and vomiting Headache Confusion Loss of energy Fatigue Restlessness and irritability Muscle weakness, spasms or cramps Seizures Unconsciousness Coma More likely you low blood CO2 is due to low K or low O2 not low sodium. You also must have a hyperventilation problem Low carbon dioxide (CO2) in the body, or hypocapnia, causes blood to be less acidic. This condition is caused by hyperventilation, or excessive ventilation. It leads to a loss of carbon dioxide from the blood. It can be done on purpose, but mostly it is involuntary. CO2 is usually eliminated from the body rather quickly. The majority of it is transported through the blood as bicarbonate, only to be transformed back into CO2 once it has reached the lungs. This process helps to regulate the acid/alkaline balance in the body. Read more: What Causes Low Co2 Levels? | eHow.com http://www.ehow.com/list_6688437_causes-low-co2-levels_.html#ixzz1cpYIFxLn > > Had a "Francis Experience" when tech wanted to take temp while taking BP! She started to head for my ear and I shook my head no. Continued and ran into hearing aid. Asked me to remove it and I shook head No again and held up 1 finger (index not middle). She got the message and waited! > > Saw Dr. K., the new Nepr. and you will never guess what his first question was: "So, have you got some BP charts for me?" Now there is a doctor that reviews the chart and obviously hasn't read the VA SOP manual! He thought he "could live with those numbers" and smiled when I asked if he thought I could! > > He then proceded to latest lab and said his only concern was my Carbon Dioxide numbers were going down (June 7=23, June 24=16, Oct 24=18 range=20 - 30). He drew a picture and blamed it on low sodium causing excess acid (blood bicarbonate level HC03). Said he wasn't making changes today but wanted me to be aware since he would be making recomendations for a new med if the trend continues. Guess I've got some researching to do! > > We talked about switching from Spiro to Epler and he saiid that would have to come from an Endo! Love the runaround! He cautioned me that it might not resolve the Gynecomastia and did I know what the next step was. I asked if it was I shave my beard and buy a dress! I then told him as far as I know it was AVS and removal or live with it. He made an endo referral! > > In the 6months he's been gone he gained alot of people skills. I thought we had a good appt. and he seemed to know about the ACCORD study and had an understanding where JNC8 is headed. > > - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with previous rt. flank pain. Treating with Meds. And DASH. . Current BP(last week ave): 131/76 HR 60 > Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and PTSD. > Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg asprin, Metformin 2000MG and Spironolactone 50 MG. >

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Assuming " normal " is within the range of 135-145, it has ALWAYS been normal

135-142.

- 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with previous rt. flank

pain. Treating with Meds. And DASH. . Current BP(last week ave): 131/76 HR 60

Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and PTSD.

Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg asprin, Metformin

2000MG and Spironolactone 50 MG.

> > > >

> > > > Had a " Francis Experience " when tech wanted to take temp while

> > taking BP! She started to head for my ear and I shook my head no.

> > Continued and ran into hearing aid. Asked me to remove it and I

> > shook head No again and held up 1 finger (index not middle). She got

> > the message and waited!

> > > >

> > > > Saw Dr. K., the new Nepr. and you will never guess what his

> > first question was: " So, have you got some BP charts for me? " Now

> > there is a doctor that reviews the chart and obviously hasn't read

> > the VA SOP manual! He thought he " could live with those numbers " and

> > smiled when I asked if he thought I could!

> > > >

> > > > He then proceded to latest lab and said his only concern was my

> > Carbon Dioxide numbers were going down (June 7=23, June 24=16, Oct

> > 24=18 range=20 - 30). He drew a picture and blamed it on low sodium

> > causing excess acid (blood bicarbonate level HC03). Said he wasn't

> > making changes today but wanted me to be aware since he would be

> > making recomendations for a new med if the trend continues. Guess

> > I've got some researching to do!

> > > >

> > > > We talked about switching from Spiro to Epler and he saiid that

> > would have to come from an Endo! Love the runaround! He cautioned me

> > that it might not resolve the Gynecomastia and did I know what the

> > next step was. I asked if it was I shave my beard and buy a dress! I

> > then told him as far as I know it was AVS and removal or live with

> > it. He made an endo referral!

> > > >

> > > > In the 6months he's been gone he gained alot of people skills. I

> > thought we had a good appt. and he seemed to know about the ACCORD

> > study and had an understanding where JNC8 is headed.

> > > >

> > > > - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with

> > previous rt. flank pain. Treating with Meds. And DASH. . Current

> > BP(last week ave): 131/76 HR 60

> > > > Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2,

> > and PTSD.

> > > > Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg

> > asprin, Metformin 2000MG and Spironolactone 50 MG.

> > > >

> > >

> >

> >

>

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SHOW ME THE MONEY! If they didn't hesitate to spray us with toxins why would

you think they would hesitate to make us grow boobs? They are saving money and

it's not their body being affected! (Besides, it makes those group showers more

fun!)

- 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with previous rt. flank

pain. Treating with Meds. And DASH. . Current BP(last week ave): 131/76 HR 60

Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and PTSD.

Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg asprin, Metformin

2000MG and Spironolactone 50 MG.

> > > >

> > > > > Had a " Francis Experience " when tech wanted to take temp while

> > taking BP! She started to head for my ear and I shook my head no.

> > Continued and ran into hearing aid. Asked me to remove it and I

> > shook head No again and held up 1 finger (index not middle). She got

> > the message and waited!

> > > > >

> > > > > Saw Dr. K., the new Nepr. and you will never guess what his

> > first question was: " So, have you got some BP charts for me? " Now

> > there is a doctor that reviews the chart and obviously hasn't read

> > the VA SOP manual! He thought he " could live with those numbers " and

> > smiled when I asked if he thought I could!

> > > > >

> > > > > He then proceded to latest lab and said his only concern was

> > my Carbon Dioxide numbers were going down (June 7=23, June 24=16,

> > Oct 24=18 range=20 - 30). He drew a picture and blamed it on low

> > sodium causing excess acid (blood bicarbonate level HC03). Said he

> > wasn't making changes today but wanted me to be aware since he would

> > be making recomendations for a new med if the trend continues. Guess

> > I've got some researching to do!

> > > > >

> > > > > We talked about switching from Spiro to Epler and he saiid

> > that would have to come from an Endo! Love the runaround! He

> > cautioned me that it might not resolve the Gynecomastia and did I

> > know what the next step was. I asked if it was I shave my beard and

> > buy a dress! I then told him as far as I know it was AVS and removal

> > or live with it. He made an endo referral!

> > > > >

> > > > > In the 6months he's been gone he gained alot of people skills.

> > I thought we had a good appt. and he seemed to know about the ACCORD

> > study and had an understanding where JNC8 is headed.

> > > > >

> > > > > - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with

> > previous rt. flank pain. Treating with Meds. And DASH. . Current

> > BP(last week ave): 131/76 HR 60

> > > > > Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2,

> > and PTSD.

> > > > > Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg

> > asprin, Metformin 2000MG and Spironolactone 50 MG.

> > > > >

> > > > >

> > > >

> > >

> >

> >

>

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Then your normal seems to be in the lower range of "normal". And for you 142 might be high- for u. May your pressure be low!CE Grim MS, MDSpecializing in DifficultHypertension

Assuming "normal" is within the range of 135-145, it has ALWAYS been normal 135-142.

- 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with previous rt. flank pain. Treating with Meds. And DASH. . Current BP(last week ave): 131/76 HR 60

Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and PTSD.

Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg asprin, Metformin 2000MG and Spironolactone 50 MG.

> > > >

> > > > Had a "Francis Experience" when tech wanted to take temp while

> > taking BP! She started to head for my ear and I shook my head no.

> > Continued and ran into hearing aid. Asked me to remove it and I

> > shook head No again and held up 1 finger (index not middle). She got

> > the message and waited!

> > > >

> > > > Saw Dr. K., the new Nepr. and you will never guess what his

> > first question was: "So, have you got some BP charts for me?" Now

> > there is a doctor that reviews the chart and obviously hasn't read

> > the VA SOP manual! He thought he "could live with those numbers" and

> > smiled when I asked if he thought I could!

> > > >

> > > > He then proceded to latest lab and said his only concern was my

> > Carbon Dioxide numbers were going down (June 7=23, June 24=16, Oct

> > 24=18 range=20 - 30). He drew a picture and blamed it on low sodium

> > causing excess acid (blood bicarbonate level HC03). Said he wasn't

> > making changes today but wanted me to be aware since he would be

> > making recomendations for a new med if the trend continues. Guess

> > I've got some researching to do!

> > > >

> > > > We talked about switching from Spiro to Epler and he saiid that

> > would have to come from an Endo! Love the runaround! He cautioned me

> > that it might not resolve the Gynecomastia and did I know what the

> > next step was. I asked if it was I shave my beard and buy a dress! I

> > then told him as far as I know it was AVS and removal or live with

> > it. He made an endo referral!

> > > >

> > > > In the 6months he's been gone he gained alot of people skills. I

> > thought we had a good appt. and he seemed to know about the ACCORD

> > study and had an understanding where JNC8 is headed.

> > > >

> > > > - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with

> > previous rt. flank pain. Treating with Meds. And DASH. . Current

> > BP(last week ave): 131/76 HR 60

> > > > Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2,

> > and PTSD.

> > > > Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg

> > asprin, Metformin 2000MG and Spironolactone 50 MG.

> > > >

> > >

> >

> >

>

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most know nothing about PA let alone meds to treat it like epelerone. From the providers perspective there's no conspiracy and I've worked at the VA (SLC, Utah) and no word comes down for something like that. It is just cheaper, and on every insurance list to use spro first, but thats just a cost thing system wide, the providers themselves and the system aren't influencing the pharm companies in a deep way as to setting prics.

In my case prescribing one drug over another does relate to cost, but only in saving the patient some cash, or helping to assure compliance as they are more likely to pay for a $4 a month as opposed to $100 a month. Reminds of when Zofran was $200 a dose and it works awesome for nausea and vominting with no real side effects, but we couldn't give it. I couldn't as it just drove cots up. So they got phenergan unless they were allergic

Subject: Re: Neperologist Appt. UpdateTo: hyperaldosteronism Date: Saturday, November 5, 2011, 10:25 PM

SHOW ME THE MONEY! If they didn't hesitate to spray us with toxins why would you think they would hesitate to make us grow boobs? They are saving money and it's not their body being affected! (Besides, it makes those group showers more fun!) - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with previous rt. flank pain. Treating with Meds. And DASH. . Current BP(last week ave): 131/76 HR 60Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and PTSD.Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg asprin, Metformin 2000MG and Spironolactone 50 MG. > > > >> > > > > Had a "Francis Experience" when tech wanted to take temp while > > taking BP! She started to head for my ear and I shook my head no. > > Continued and ran into hearing aid. Asked me to remove it and I > > shook head No again and held up 1 finger (index not middle). She got > > the message and waited!> > > > >> > > > > Saw Dr. K., the new Nepr. and you will never guess what his > > first question was: "So, have you got some BP charts for me?" Now > > there is a doctor that reviews the chart and obviously hasn't read > > the VA SOP manual! He thought he "could live with those numbers" and > > smiled when I asked if he thought I could!> > > > >> > > > > He then proceded to latest lab and said his

only concern was > > my Carbon Dioxide numbers were going down (June 7=23, June 24=16, > > Oct 24=18 range=20 - 30). He drew a picture and blamed it on low > > sodium causing excess acid (blood bicarbonate level HC03). Said he > > wasn't making changes today but wanted me to be aware since he would > > be making recomendations for a new med if the trend continues. Guess > > I've got some researching to do!> > > > >> > > > > We talked about switching from Spiro to Epler and he saiid > > that would have to come from an Endo! Love the runaround! He > > cautioned me that it might not resolve the Gynecomastia and did I > > know what the next step was. I asked if it was I shave my beard and > > buy a dress! I then told him as far as I know it was AVS and removal > > or live with it. He made an endo

referral!> > > > >> > > > > In the 6months he's been gone he gained alot of people skills. > > I thought we had a good appt. and he seemed to know about the ACCORD > > study and had an understanding where JNC8 is headed.> > > > >> > > > > - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with > > previous rt. flank pain. Treating with Meds. And DASH. . Current > > BP(last week ave): 131/76 HR 60> > > > > Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, > > and PTSD.> > > > > Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg > > asprin, Metformin 2000MG and Spironolactone 50 MG.> > > > >> > > > >> > > >> > >> >>

>>

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This is an interesting subject Spiro vs Eper. My doc and I looked up the meds

in his database at Wash U that includes monthly costs based on my insurance.

The cost of Spiro $80, the cost of Eper $100. Both prices are per month and are

applied towards insurance deductible which in my case is $3000 per year. So for

my insurance there is not much difference.

However, my endos main reason for choosing Spiro for as long as possible is

safety/risk. The way he explained it is that Wash U has a history of treating

patients long term with Spiro. Some over 20 years. There is a ton of

info/medical research on the long term effects of Spiro. He explained that

there is not a lot of information about what happens when someone is treated

with Eper for over 5 years. In his opinion, it is possibly risky until long

term studies show that there is no harm in long term use of Eper.

So his strategy is to treat patients as long as possible on Spiro. If they

don't tolerate Spiro well he switches to Eper. He really encourages trying to

tolerate Spiro well (reducing salt, weight, exercising). He doesn't mention

DASH but instead focuses on the sodium part of the equation.

I just thought this was interesting. He basically told me that I should take

Spiro until I can't have sex on command (sorry for being crude ladies) or my

blood pressure is no longer controlled on a reasonable dose and diet. At that

point I can switch to Eper.

> > > > >

> > > > > > Had a " Francis Experience " when tech wanted to take temp while

> > > taking BP! She started to head for my ear and I shook my head no.

> > > Continued and ran into hearing aid. Asked me to remove it and I

> > > shook head No again and held up 1 finger (index not middle). She got

> > > the message and waited!

> > > > > >

> > > > > > Saw Dr. K., the new Nepr. and you will never guess what his

> > > first question was: " So, have you got some BP charts for me? " Now

> > > there is a doctor that reviews the chart and obviously hasn't read

> > > the VA SOP manual! He thought he " could live with those numbers " and

> > > smiled when I asked if he thought I could!

> > > > > >

> > > > > > He then proceded to latest lab and said his only concern was

> > > my Carbon Dioxide numbers were going down (June 7=23, June 24=16,

> > > Oct 24=18 range=20 - 30). He drew a picture and blamed it on low

> > > sodium causing excess acid (blood bicarbonate level HC03). Said he

> > > wasn't making changes today but wanted me to be aware since he would

> > > be making recomendations for a new med if the trend continues. Guess

> > > I've got some researching to do!

> > > > > >

> > > > > > We talked about switching from Spiro to Epler and he saiid

> > > that would have to come from an Endo! Love the runaround! He

> > > cautioned me that it might not resolve the Gynecomastia and did I

> > > know what the next step was. I asked if it was I shave my beard and

> > > buy a dress! I then told him as far as I know it was AVS and removal

> > > or live with it. He made an endo referral!

> > > > > >

> > > > > > In the 6months he's been gone he gained alot of people skills.

> > > I thought we had a good appt. and he seemed to know about the ACCORD

> > > study and had an understanding where JNC8 is headed.

> > > > > >

> > > > > > - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with

> > > previous rt. flank pain. Treating with Meds. And DASH. . Current

> > > BP(last week ave): 131/76 HR 60

> > > > > > Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2,

> > > and PTSD.

> > > > > > Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg

> > > asprin, Metformin 2000MG and Spironolactone 50 MG.

> > > > > >

> > > > > >

> > > > >

> > > >

> > >

> > >

> >

>

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Sounds familiar. We need to update them on DASH THOUGH Or when you get painful breasts. How has DASH Spiro helped?May your pressure be low!CE Grim MS, MDSpecializing in DifficultHypertension

This is an interesting subject Spiro vs Eper. My doc and I looked up the meds in his database at Wash U that includes monthly costs based on my insurance. The cost of Spiro $80, the cost of Eper $100. Both prices are per month and are applied towards insurance deductible which in my case is $3000 per year. So for my insurance there is not much difference.

However, my endos main reason for choosing Spiro for as long as possible is safety/risk. The way he explained it is that Wash U has a history of treating patients long term with Spiro. Some over 20 years. There is a ton of info/medical research on the long term effects of Spiro. He explained that there is not a lot of information about what happens when someone is treated with Eper for over 5 years. In his opinion, it is possibly risky until long term studies show that there is no harm in long term use of Eper.

So his strategy is to treat patients as long as possible on Spiro. If they don't tolerate Spiro well he switches to Eper. He really encourages trying to tolerate Spiro well (reducing salt, weight, exercising). He doesn't mention DASH but instead focuses on the sodium part of the equation.

I just thought this was interesting. He basically told me that I should take Spiro until I can't have sex on command (sorry for being crude ladies) or my blood pressure is no longer controlled on a reasonable dose and diet. At that point I can switch to Eper.

> > > > >

> > > > > > Had a "Francis Experience" when tech wanted to take temp while

> > > taking BP! She started to head for my ear and I shook my head no.

> > > Continued and ran into hearing aid. Asked me to remove it and I

> > > shook head No again and held up 1 finger (index not middle). She got

> > > the message and waited!

> > > > > >

> > > > > > Saw Dr. K., the new Nepr. and you will never guess what his

> > > first question was: "So, have you got some BP charts for me?" Now

> > > there is a doctor that reviews the chart and obviously hasn't read

> > > the VA SOP manual! He thought he "could live with those numbers" and

> > > smiled when I asked if he thought I could!

> > > > > >

> > > > > > He then proceded to latest lab and said his only concern was

> > > my Carbon Dioxide numbers were going down (June 7=23, June 24=16,

> > > Oct 24=18 range=20 - 30). He drew a picture and blamed it on low

> > > sodium causing excess acid (blood bicarbonate level HC03). Said he

> > > wasn't making changes today but wanted me to be aware since he would

> > > be making recomendations for a new med if the trend continues. Guess

> > > I've got some researching to do!

> > > > > >

> > > > > > We talked about switching from Spiro to Epler and he saiid

> > > that would have to come from an Endo! Love the runaround! He

> > > cautioned me that it might not resolve the Gynecomastia and did I

> > > know what the next step was. I asked if it was I shave my beard and

> > > buy a dress! I then told him as far as I know it was AVS and removal

> > > or live with it. He made an endo referral!

> > > > > >

> > > > > > In the 6months he's been gone he gained alot of people skills.

> > > I thought we had a good appt. and he seemed to know about the ACCORD

> > > study and had an understanding where JNC8 is headed.

> > > > > >

> > > > > > - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with

> > > previous rt. flank pain. Treating with Meds. And DASH. . Current

> > > BP(last week ave): 131/76 HR 60

> > > > > > Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2,

> > > and PTSD.

> > > > > > Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg

> > > asprin, Metformin 2000MG and Spironolactone 50 MG.

> > > > > >

> > > > > >

> > > > >

> > > >

> > >

> > >

> >

>

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Francis, do you know the address where you found this? I have to read it again

but don't think they even mention PA, maybe we need to wake them up!

Thanks....

> > >

> > > > Had a " Francis Experience " when tech wanted to take temp while

> taking BP! She started to head for my ear and I shook my head no.

> Continued and ran into hearing aid. Asked me to remove it and I shook

> head No again and held up 1 finger (index not middle). She got the

> message and waited!

> > > >

> > > > Saw Dr. K., the new Nepr. and you will never guess what his first

> question was: " So, have you got some BP charts for me? " Now there is a

> doctor that reviews the chart and obviously hasn't read the VA SOP

> manual! He thought he " could live with those numbers " and smiled when I

> asked if he thought I could!

> > > >

> > > > He then proceded to latest lab and said his only concern was my

> Carbon Dioxide numbers were going down (June 7=23, June 24=16, Oct 24=18

> range=20 - 30). He drew a picture and blamed it on low sodium causing

> excess acid (blood bicarbonate level HC03). Said he wasn't making

> changes today but wanted me to be aware since he would be making

> recomendations for a new med if the trend continues. Guess I've got some

> researching to do!

> > > >

> > > > We talked about switching from Spiro to Epler and he saiid that

> would have to come from an Endo! Love the runaround! He cautioned me

> that it might not resolve the Gynecomastia and did I know what the next

> step was. I asked if it was I shave my beard and buy a dress! I then

> told him as far as I know it was AVS and removal or live with it. He

> made an endo referral!

> > > >

> > > > In the 6months he's been gone he gained alot of people skills. I

> thought we had a good appt. and he seemed to know about the ACCORD study

> and had an understanding where JNC8 is headed.

> > > >

> > > > - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with

> previous rt. flank pain. Treating with Meds. And DASH. . Current BP(last

> week ave): 131/76 HR 60

> > > > Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and

> PTSD.

> > > > Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg

> asprin, Metformin 2000MG and Spironolactone 50 MG.

> > > >

> > > >

> > >

> >

>

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Share on other sites

This is the web page. will need to click on Aldosterone Antagonists (Eplerenone,

Spironolactone) in Heart Failure, Recommendations for Use

http://www.index.va.gov/search/va/va_search.jsp?SQ= & TT=1 & QT=Eplerenone & searchbtn\

=Search

> > > >

> > > > > Had a " Francis Experience " when tech wanted to take temp while

> > taking BP! She started to head for my ear and I shook my head no.

> > Continued and ran into hearing aid. Asked me to remove it and I shook

> > head No again and held up 1 finger (index not middle). She got the

> > message and waited!

> > > > >

> > > > > Saw Dr. K., the new Nepr. and you will never guess what his first

> > question was: " So, have you got some BP charts for me? " Now there is a

> > doctor that reviews the chart and obviously hasn't read the VA SOP

> > manual! He thought he " could live with those numbers " and smiled when I

> > asked if he thought I could!

> > > > >

> > > > > He then proceded to latest lab and said his only concern was my

> > Carbon Dioxide numbers were going down (June 7=23, June 24=16, Oct 24=18

> > range=20 - 30). He drew a picture and blamed it on low sodium causing

> > excess acid (blood bicarbonate level HC03). Said he wasn't making

> > changes today but wanted me to be aware since he would be making

> > recomendations for a new med if the trend continues. Guess I've got some

> > researching to do!

> > > > >

> > > > > We talked about switching from Spiro to Epler and he saiid that

> > would have to come from an Endo! Love the runaround! He cautioned me

> > that it might not resolve the Gynecomastia and did I know what the next

> > step was. I asked if it was I shave my beard and buy a dress! I then

> > told him as far as I know it was AVS and removal or live with it. He

> > made an endo referral!

> > > > >

> > > > > In the 6months he's been gone he gained alot of people skills. I

> > thought we had a good appt. and he seemed to know about the ACCORD study

> > and had an understanding where JNC8 is headed.

> > > > >

> > > > > - 65 yo super ob. male - 12mm X 13mm rt. a.adnoma with

> > previous rt. flank pain. Treating with Meds. And DASH. . Current BP(last

> > week ave): 131/76 HR 60

> > > > > Other Issues/Opportunities: OSA w Bi-Pap settings 13/19, DM2, and

> > PTSD.

> > > > > Meds: Duloxetine hcl 80 MG, Metoprolol Tartrate 200 MG, 81mg

> > asprin, Metformin 2000MG and Spironolactone 50 MG.

> > > > >

> > > > >

> > > >

> > >

> >

>

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