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1.3.2: Assess and modify individualized treatment plans, considering safety of therapy

UK is a 66-year-old woman with a history of ischemic cardiomyopathy who presents to urgent care with symptoms consistent with NYHA class IV HF. Past medical history includes hypertension, hyperlipidemia, diabetes mellitus, myocardial infarction, and hypothyroidism. UK complains of progressive weight gain (~8 lb increase since her previous visit 3 months ago), shortness of breath at rest, 1 pillow orthopnea, and occasional paroxysmal nocturnal dyspnea (PND). Her physical examination is positive for 1+ pitting edema in her ankles. Vital signs include BP 112/73 mm Hg and HR 88 bpm. Laboratory results include: potassium 3.7 mmol/L, BUN 35 mg/dL, and serum creatinine 1.4 mg/dL. UK's current medications are levothyroxine 0.05 mg daily, furosemide 20 mg twice daily, lisinopril 20 mg daily, atorvastatin 40 mg daily, aspirin 81 mg daily, insulin glargine 46 units at bedtime, and insulin aspart 6 units before meals.

Which of the following is the best treatment option to manage UK's hypokalemia and fluid overload?

(A) Continue furosemide 20 mg twice daily.

(B) Increase furosemide to 80 mg twice daily.

(C) Initiate spironolactone 25 mg once daily.

(D) Increase furosemide to 40 mg twice daily and initiate spironolactone to 25 mg once daily.

The Correct Answer is: D

While the addition of a potassium supplement could be considered, the addition of spironolactone along with the diuretic dose increase would provide additional mortality benefit as well as result in potassium retention. When added to standard HF therapy in patients with NYHA class III or IV HF symptoms, spironolactone has been shown to reduce mortality (D).

UK is experiencing fluid overload based upon signs and symptoms and the current loop diuretic dose is inadequate (A). Increasing the furosemide dose alone (B) is inappropriate, as it will worsen UK's relatively low serum potassium. Spironolactone alone (C) at the low doses used to reduce mortality in HF does not commonly result in clinically meaningful diuresis.

UK is a 66-year-old woman with a history of ischemic cardiomyopathy who presents to urgent care with symptoms consistent with NYHA class IV HF. Past medical history includes hypertension, hyperlipidemia, diabetes mellitus, myocardial infarction, and hypothyroidism. UK complains of progressive weight gain (~8 lb increase since her previous visit 3 months ago), shortness of breath at rest, 1 pillow orthopnea, and occasional paroxysmal nocturnal dyspnea (PND). Her physical examination is positive for 1+ pitting edema in her ankles. Vital signs include BP 112/73 mm Hg and HR 88 bpm. Laboratory results include: potassium 3.7 mmol/L, BUN 35 mg/dL, and serum creatinine 1.4 mg/dL. UK's current medications are levothyroxine 0.05 mg daily, furosemide 20 mg twice daily, lisinopril 20 mg daily, atorvastatin 40 ...

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