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On enac 10. Noticed swelling below knee, mild anemia and low potassium level. What to do?

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My father is indian, Doctor my father aged 74, had a pneuomonia( hospitalised and cured 2010), fell down in 2009 , CT SCAN REVEALED cerbral atophy left side, ecg left axis deviation, Doctors treatment ASOMEX 0.5 , Proloabmmet 12.5 , Enace 10,Doxolin 1/2-1/2-1/2, angizem cd 30 mg once daily , Aztor 5 mg daily night and inhalers. when he is using Enace D 10 Na is getting down and potasium is getting low, When he is using Enace 10 both legs down below knee are swelling.

Urea 38, Na 120 K -2.5 , Hb 10.5 , Crarinine 1.7 , Slight albumin in Urine. Lipid Normal , Thyroid Normal.

My father test result is prior to switching over to medicine enace 10 inlieu of enace d10. Recent BP is 160/80 , one day back.

Pl suggest waht to do?
Posted Thu, 22 Nov 2012 in General Health
Answered by Dr. Anantharamakrishnan 2 hours later

Your father has several problems – some of them need URGENT attention
My suggestion is to admit him under the care of a nephrologist, as soon as possible.

Pneumonia in 2010 and cured – can cause no problems now
Cerebral atrophy 2009 – from age and atherosclerosis – nothing to do at present
ECG left axis deviation – result of blood pressure – Not of concern

Low sodium / low potassium / higher creatinine / mild anaemia / swollen legs
\ Hypertension \ Asthma? \ Cholesterol? \

Mild renal impairment (creatinine 1.7), slight albumin in urine – from long term pressure affecting the kidneys – no need to deal directly. Keep the pressure controlled and regular follow up
Mild anaemia – multiple reasons, possibly food intake may be primary
Sodium is low from the diuretic (D in Enace-D). It is usually dilutional hyponatremia – the proportion of body sodium in relation to the water is low. The usual approach is to stop the diuretic and restrict the daily intake of water
There are several reasons for low potassium –diuretic is again number one. The dose of 25 mg in Eance-D is not tolerated by many. The usual dose is 12.5 mg. Even that can be responsible.
The ‘inhaler’ - you have not mentioned the name. Probably it contains albuterol (Salbutamol) – it is a well known cause for bringing down potassium. Actually it is an emergency treatment for increased potassium in hospital settings.
There may be several reasons for the swelling – heart failure is number one cause.
Amlodipine (asomex) may be contributing – it dilates the blood vessels
Right sided heart failure (Cor Pulmonale) is also a possibility – suggested by the use of doxyfylline and inhaler
It could also be weakness of valves veins of the leg from age...
It is better to tolerate a little swelling than to get several complications from trying to get rid of it.

It will prove to be very difficult to manage as outpatient.
The best solution will be to ADMIT HIM IN A MULTI-SPECIALITY TERTIARY CARE HOSPITAL, as soon as possible, under the care of a NEPHROLOGIST – he may need daily – even more than once in a day – measurement of electrolytes, kidney function, pressure and clinical status.
The doctor in charge can co-operate with different specialists – Thiazide to be withdrawn / fluids restricted / only one calcium blocker(Asomex alone and stopping angisem), instead of the two, he is now receiving / withholding the inhaler / trying to replace ACE blocker by Aldosterone antagonist /etc.

Discuss about these possibilities with the treating doctor.

Hope this helped. Do write back if you need more information

Take care
God bless him
Good luck
Above answer was peer-reviewed by
Follow-up: On enac 10. Noticed swelling below knee, mild anemia and low potassium level. What to do? 21 hours later
Thank you very much Dr. for your advise.

1) My father is taking Avesta Inhaler ( thrice Daily)
2) Asomex (Amlodipine) use will lead to swelling?
3) How to prevent the stoke by using medicine.
4) Prolomet 12.5 - is it a ACE blocker or beta blocker then your last suggestion
(trying to replace ACE blocker by Aldosterone antagonist ) is understandable to us . Now sir is Aldosterone antagonist a diuretic.
5) Withdrawl of Angizem is a good suggestion. By which medicine
how to prevent stroke?
6) Fluid how many glasses of water in this case to use.
7) What will be the dose of Aldosterone antagonist
8) Whether inhaler withdrwal in cold will cause problem.
9) What will be the BP medicine dose?
10) 1 more point i like to share with you after taking Enace 10 & angizem in the morning he develops leg swelling?

Doctor kindly adice the correct cardio medicine to keep the bp <= 140/80

As you suggested we will be consuting with a nephologist shortly?
any advice regarding food?
whether Cherry fruits can be used?
Answered by Dr. Anantharamakrishnan 9 hours later
I have already written in great detail. I think you have not got the point.
Your father's condition is serious. He needs admission - as soon as possible. He has to be under the care of nephrologist this time. His blood tests must be repeated several times and closely followed up. It is risky to delay or treat from home.

Anyhow, I am answering your questions -
•      My father is taking Avesta Inhaler ( thrice Daily) -
It looks like spelling error - What are the ingredients? I think it is avessa – it contains, beta agonist and can bring down potassium
•     Asomex (Amlodipine) use will lead to swelling?
Yes, it can. It dilates the blood vessel. But there are several other reasons for swelling – like heart, kidney, venous incompetence and so on. The examining doctor can detect clues.
•      How to prevent the stoke by using medicine
Stroke? – not stoke...nothing can prevent. Aspirin and clopidgrel can greatly reduce the incidence.
•      Prolomet 12.5 - is it a ACE blocker or beta blocker
It is beta blocker metoprolol.
•     is Aldosterone antagonist a diuretic
Yes, Aldactone is a diuretic, not strong by itself. It retains potassium – not like other diuretics. It helps the heart .
•     Withdrawl of Angizem is a good suggestion. By which medicine how to prevent stroke?
Good control of pressure and cholesterol will help. There is no special medicine.- aspirin and clopidogrel help, as I said before
•     Fluid how many glasses of water in this case to use
Just 2 glasses first day. Sodium and potassium have to be measured daily, some times more than once in a day. Fluids are adjusted according to results.
•     The general starting dose of aldosterone is 25 mg twice. It can be stepped up – easily doubled, even more. But it should ONLY BE GIVEN BY DOCTOR AND NEEDS MONITORING BLOOD PRESSURE, ELECTROLYTES AND KIDNEY FUNCTION
•     Why was the inhlaer started? Why is it being continued? Has he wheezing now? How is his lung function? That alone can give a clue - as to the effect of stopping. [It is given for asthma]
•      Neither Enace nor angizem is the cause of swelling
•     Calcium blockers, beta blockers, diuretics all help in BP
•     Low fat, low salt diet is the basic food. Most fruits have potassium – banana, orange, prunes and so on

Good luck - Admit him immediately - he needs close observation

Above answer was peer-reviewed by
Follow-up: On enac 10. Noticed swelling below knee, mild anemia and low potassium level. What to do? 18 hours later
Doctor his potasium level now only 2.5, before taht it was within normal range but the Sodium ( 120 to 134) range.

Aldosterone antagonist - name some medicines can they reduce the sodium level.

Answered by Dr. Anantharamakrishnan 10 hours later
Thanks for writing back.
Aldosterone antagonist is also a diuretic - It can and will reduce sodium. Spironolactone is the oldest and cheapest. Eplerenone is a later one and costly. Potassium at 2.5 rings an alarm bell. I would urge to ADMIT him in a hospital. Such a low potassium is XXXXXXX as it affects the heart - it can cause arrhythmia which can bring the heart to a standstill. Please admit him
Take care

Above answer was peer-reviewed by
Follow-up: On enac 10. Noticed swelling below knee, mild anemia and low potassium level. What to do? 6 days later
Dear Dr

Our treating dr has dropped prolomet 12.5 in the morning and added Dytor 5 mg (1-0-0) for 15 days and has told to test the Na, K, Creatinine and also told to withdraw Doxolin and inhaler gradually.

Now my question is with Dytor whether Na, K will be changed.

Enace/asomex/dytor/aztor/doxolin is it the right combination? chosen by dr.
and for sleep problem whether acibrium can be used.
Nephrlogist has told to used dytor for 5 days and stopped and then get blood tested after 7 days.
then my question is withdrwal of dytor , will it create the problem again.
or to reduce sweeling dytor will be used and when sweeling will be stopped dytor will be stopped ,then during the discontinue period for dytor which medicine will take care of BP. prolomet has been withdrwan.
Fluid has been restricted to 1.250 Lit per day.
Or Enace for 5 days and enace D on 6th day then again enace
Pl. advise. Because i am only an engineer.
Answered by Dr. Anantharamakrishnan 6 hours later
I have given some information to your queries one by one –

Dytor can change Na, K / Along with fluid restriction and with Enace - Na K may correct

Regarding sleep medicine, only the doctor at bed side can decide, based on his overall condition.

Asomex also treats BP

Medicines are ‘in right combination’

The treating nephrologist alone can decide the medicine to be given and the dose - depending on doctor’s clinical findings, patient’s general condition, pressure, results of blood test and so on – No one else can predict beforehand. The nephrologist is doing the best for your father. Keep in constant touch with him.

Good luck
Above answer was peer-reviewed by
Follow-up: On enac 10. Noticed swelling below knee, mild anemia and low potassium level. What to do? 2 days later
Thank u Dr.
With dytor 5 mg and other latest combination of medicines , my father bp has become 140/80, and 80% of his leg swelling has reduced with fliud restriction and dytor 5 mg . Now sir we r fearing if his Na & K getting affected, after reduction of leg sweeling can we stop dytor 5 and then go for testing of serum eletrolyte and creatinine.

Actually Nephro doctor suugested to stop after 4th day dytor 10 mg or once edema redces and then go for testing on 7 th day.

But treating cardiodoctor suugested us to take the dytor 5 everyday and after testing to XXXXXXX him on 15 th day.

Right now he is taking Enace/asomex/dytor 5 /aztor/doxolin
sir, kindly advise.
Answered by Dr. Anantharamakrishnan 3 hours later
Glad to know that your father is improving clinically.
But we also need to have laboratory results to improve.

My suggestion will be to ask the two consultants to talk to each other...and arrive at a consensus.
In case that is not possible, follow the nephrologist's advice - stop the drug and repeat electrolytes and renal function. Further management will be decided by the nephrlogist, based on the lab report.

Good luck
God bless
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