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Suggest Treatment For Swelling In The Ankles
Question: thank you, I am an 82 year old guy, still working 7 days a week, in major real estate development and construction in 6 states, but love my work so much that I can!t stop, i however I am in a position that I am basically in a 0 stress situation, 14 years ago I became a serious type 2 diabetic, so serious I jumped over the metformin stage and it was necessary to take 70 units of insulin ( HUMILIN) morning and night, my a1c at one time ran as high as 9, 2 years later as expected here comes stage 2 hypertension, at one time 5 medications 3 times per day, I did some research and started balancing all of my hormones, in 2 years to the amazement of my pcp, I eliminated my diabetes, haven!t had an a1c over 4.8 for over 1 year, I have balanced all of my hormones as well as my thyroid which when I started was 67 % deficient, my blood pressure meds are down to 3 morning and night, still a bit high but still improving, about 6 months ago I started having swelling a little bit in my ankles, but much more in the tops of my feet just a little forward of the arch in my feet, the swelling is not painful at all but is quite puffy, would you think that may be due to some blood flow restriction ? my pcp is like most, unless its of an emergency nature, he has at a XXXXXXX about 15 minutes on a regular visit, do you think I should have any specific test to determine the cause , or what have you experienced in this area, please help me with my country boy PHD, I!m XXXXXXX XXXX
Brief Answer:
I would recommend performing some tests:
Detailed Answer:
Hello XXXX!
Welcome back again on HCM!
I am glad that you have stabilized your blood pressure levels and fasting glucose.
Regarding the swelling your ankles, I would explain that this can be related to different causes:
- fluid retention (caused by possible heart failure, kidney disease or liver disease)
- an electrolyte imbalance
- chronic vein insufficiency in the lower limbs.
For this reason, I would recommend consulting with your attending physician for a physical exam and performing some tests to investigate for the possible cause:
- a cardiac ultrasound to examine your cardiac function and structure and exclude possible heart failure
- liver and kidney function tests
- blood electrolytes and blood osmolarity
- an urine analysis
- a Doppler ultrasound of the lower limbs vessels would be necessary if suspicions of possible chronic vein insufficiency (varicose veins) are raised.
You should discuss with your doctor on the above issues.
Hope to have been helpful to you!
Feel free to ask me again whenever you need!
Kind regards,
Dr. Iliri
I would recommend performing some tests:
Detailed Answer:
Hello XXXX!
Welcome back again on HCM!
I am glad that you have stabilized your blood pressure levels and fasting glucose.
Regarding the swelling your ankles, I would explain that this can be related to different causes:
- fluid retention (caused by possible heart failure, kidney disease or liver disease)
- an electrolyte imbalance
- chronic vein insufficiency in the lower limbs.
For this reason, I would recommend consulting with your attending physician for a physical exam and performing some tests to investigate for the possible cause:
- a cardiac ultrasound to examine your cardiac function and structure and exclude possible heart failure
- liver and kidney function tests
- blood electrolytes and blood osmolarity
- an urine analysis
- a Doppler ultrasound of the lower limbs vessels would be necessary if suspicions of possible chronic vein insufficiency (varicose veins) are raised.
You should discuss with your doctor on the above issues.
Hope to have been helpful to you!
Feel free to ask me again whenever you need!
Kind regards,
Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
I don't see where u answered my question about my morning high systolic 170/180 levels maybe I failed to submit..........anyway my current medications are 160,12.5 valsartan, 20mg lisinipril, 0.3 clonidine, 2.5 minoxidil 5 mg amlodipine all twice a day, 7 am 8 pm, my diastolic and heart rate are always awesome, I want to keep my systolic pressure 150 or less, however I feel better when it is between 130/150,it seems to me that I may need another medication, maybe a time release type at night to drop my morning pressures, I have read that calcium channel blockers are some times more effective in the elderly, give me your thoughts on this and if u think I need an additional medication could you give me what you might consider best for my circumstances, thanks, I!m XXXXXXX XXXX
Brief Answer:
I would recommend as follows:
Detailed Answer:
Dear XXXXXXX
I didn't find before your question on your blood pressure.
It is true that values like 170/180 are really high and can damage your blood vessels when they persist for a long time. It is really important to have a better control of your blood pressure.
From the other hand, medications used should be evaluated for their possible adverse effects and tolerance.
I would not recommend increasing the dose of amlodipine or add any other calcium channel blocker as they are known to cause or exacerbate leg swelling. So, considering the fact that you have this symptoms, I would not recommend increasing the dose of amlodipine (at least without performing the above mentioned tests to investigate for other possible causes).
Instead of doing this, I would recommend adding a diuretic drug like Torsemide. You can start 2.5-5 mg/day PO initially; increased to 10 mg/day PO in 4-6 weeks. It will also help you with the leg swelling, besides reducing your blood pressure values.
Another change to your therapy that I would consider is switching from clonidine to methyldopa (aldomet). You can start 250mg twice daily and increase the dose up to 1000mg per day. It is known that aldomet has a longer half life than clonidine. This makes its effect last longer and have a better control through 24 hours of the day of your blood pressure values (clonidine effects lasts for some hours and it is really effective during the night sleep).
I would also recommend checking your potassium levels as valsartan when used concomitantly with lisinopril can cause an increase in potassium plasma levels (they are of a similar pharmacological class of drugs). I would recommend also considering increasing valsartan dose (double dose) and stop taking lisinopril as using both these drugs concomitantly can cause a lot of adverse effects.
You should discuss with your doctor on the above possible treatment options.
Hope you will find this answer helpful!
Best wishes,
Dr. Iliri
I would recommend as follows:
Detailed Answer:
Dear XXXXXXX
I didn't find before your question on your blood pressure.
It is true that values like 170/180 are really high and can damage your blood vessels when they persist for a long time. It is really important to have a better control of your blood pressure.
From the other hand, medications used should be evaluated for their possible adverse effects and tolerance.
I would not recommend increasing the dose of amlodipine or add any other calcium channel blocker as they are known to cause or exacerbate leg swelling. So, considering the fact that you have this symptoms, I would not recommend increasing the dose of amlodipine (at least without performing the above mentioned tests to investigate for other possible causes).
Instead of doing this, I would recommend adding a diuretic drug like Torsemide. You can start 2.5-5 mg/day PO initially; increased to 10 mg/day PO in 4-6 weeks. It will also help you with the leg swelling, besides reducing your blood pressure values.
Another change to your therapy that I would consider is switching from clonidine to methyldopa (aldomet). You can start 250mg twice daily and increase the dose up to 1000mg per day. It is known that aldomet has a longer half life than clonidine. This makes its effect last longer and have a better control through 24 hours of the day of your blood pressure values (clonidine effects lasts for some hours and it is really effective during the night sleep).
I would also recommend checking your potassium levels as valsartan when used concomitantly with lisinopril can cause an increase in potassium plasma levels (they are of a similar pharmacological class of drugs). I would recommend also considering increasing valsartan dose (double dose) and stop taking lisinopril as using both these drugs concomitantly can cause a lot of adverse effects.
You should discuss with your doctor on the above possible treatment options.
Hope you will find this answer helpful!
Best wishes,
Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
thank you very much, that was a terrific and thorough answer, however I don't see how I can double the valsartan because I am already taking 160 mg morning and night, my understanding is that 320 mg per day is maximum dosage, am I missing something ? I think the aldomet is a great idea, as you know I have been wanting to get off both clonidine and minoxidil for a long time, I had never heard of torsemide, I was on fourosimide 40 mg twice daily for 10 years and developed stage 3 chronic kidney desease, I finally got it reversed, my kidneys back to normal after a 2 year effort. my potassium levels were great in XXXXXXX of this, however I will test it again soon. in the event I cannot add any valsartan what would suggest then COACH ??? thank u so much, I will discuss this in detail with my primary care physician thank u so much , XXXXXXX XXXX
Brief Answer:
My opinion as follows:
Detailed Answer:
Dear XXXXXXX
I agree with you about valsartan that this is the maximal daily dose ( I didn't notice that you take it twice daily). It is true that you can not increase the dose any more.
I recommend checking time after time your potassium plasma levels for the above mentioned reasons.
Regarding Torsemide, it is the same pharmacological class as furosemide. Considering the complications of furosemide ( even though renal disease is not a common complication of this drug, as it is used usually to relieve edema in renal disease), possible similar complications can occur, but we can not be sure about that.
Coming to this point, I would recommend switching gradually from clonidine to methyldopa, with a starting dose of 250mg twice daily, increasing the dose up to 1000mg daily.
You should discuss with your doctor on the above issues.
Hope you will find this answer helpful!
I remain at your disposal whenever you have any other uncertainties!
Greetings!
Dr. Iliri
My opinion as follows:
Detailed Answer:
Dear XXXXXXX
I agree with you about valsartan that this is the maximal daily dose ( I didn't notice that you take it twice daily). It is true that you can not increase the dose any more.
I recommend checking time after time your potassium plasma levels for the above mentioned reasons.
Regarding Torsemide, it is the same pharmacological class as furosemide. Considering the complications of furosemide ( even though renal disease is not a common complication of this drug, as it is used usually to relieve edema in renal disease), possible similar complications can occur, but we can not be sure about that.
Coming to this point, I would recommend switching gradually from clonidine to methyldopa, with a starting dose of 250mg twice daily, increasing the dose up to 1000mg daily.
You should discuss with your doctor on the above issues.
Hope you will find this answer helpful!
I remain at your disposal whenever you have any other uncertainties!
Greetings!
Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
thanks, in the event we change from clonidine to low dose methyldopa to start and work up the strength if and as needed do you feel that will solve my stage 2 systolic pressures in the morning ? I know theres no way to tell with certainty , the early mornings are the only time I have a problem, when I get home at night my stystolic pressure is rarely over 140 +/- and that's around what I would like it to be 24 hours a day, more or less, I hope u don't get tired fooling with me, I really am grateful for your wisdom, thanks again, I!m XXXXXXX XXXX...................
Brief Answer:
My opinion as follows:
Detailed Answer:
Dear XXXXXXX
There is really no way to be sure about this.
But we can try to make some modifications like take one tablet during the morning and two tablets of methyldopa during the evening, in order to have a better blood pressure control during the night. We can raise the dose up to 4 tablets a day (morning, lunch, and two tablets in the evening).
These changes need up to a week to achieve a new balance in your blood pressure.
You should just be a little patient!
I am always at your disposal if you have any other uncertainties!
Regards,
Dr. Iliri
My opinion as follows:
Detailed Answer:
Dear XXXXXXX
There is really no way to be sure about this.
But we can try to make some modifications like take one tablet during the morning and two tablets of methyldopa during the evening, in order to have a better blood pressure control during the night. We can raise the dose up to 4 tablets a day (morning, lunch, and two tablets in the evening).
These changes need up to a week to achieve a new balance in your blood pressure.
You should just be a little patient!
I am always at your disposal if you have any other uncertainties!
Regards,
Dr. Iliri
Note: For further queries related to coronary artery disease and prevention, click here.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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