Question: Hi, Dr. Grief, I care for my mother past 13 years. She is 82 years old. She had a CVA and now is a hemiplegic, on/off vascular dementia, dysphagia. This year her blood pressure increased and we [the doc and I] tried many different combinations of antiphypertensive meds. Before this last change she was on 100mg atenolol, 7.5mg vasotec in divided doses and 10mg norvasc. But the increase in Vasotec from 5mg to 7.5mg caused her regular headaches, which triggers her dementia bouts, lose of quality of life and difficult to care for. So we went to a heart specialist and he recommended spironolactone. It's been 7 days on it now, yet she is having out-of-the-ordinary mood swings, confusion, tiredness, crying, wants to die (and lack of appetite). The pharmaceutical phamplet says to contact doctor immediately if the patient has unusual mood/mental changes. My question is should I stop the drug; or wait until a full 2 weeks has passed because maybe it is just a body adjustment to the drug.

Hi, Dr. Mittal, Thank you so much for your reply and recommendation! You are right to intuitively extrapolate from my monologue that we are having difficulty reducing my mother's b.p. at this time. Some years, post-stroke, her bp goes down and we reduce the combination of meds; other years the opposite--her bp goes up and we have to add another bp med. This year has been the challenge. She experiencing intolerable side effects or has allergic reactions. Our family doctor has run out of suggestions and the cardiologist we saw last month said our only other option was to try spironolactone. So it would be great if you could offer an alternative. So here's the rundown (I hope you can figure out the table below)-- Year Name Dosage Reaction Comments 1997 (Pre-stroke) Novo-Triamzide-combination drug of Triamterene & hydro-chlorothiazide, which the latter is a Sulphonamide 50/25mg, o.d. • Unknown Contraindicated for diabetics 1998 (Pre-stroke) Adalat (like Norvasc, calcium channel blocker) 30mg, o.d. • Unknown 2007 Vasotec 10mg, o.d. • Headaches • Nausea (& recent vomiting @ 7.5mg) • Stomach cramps; both times: then & now B.P. 138/85; was also on nitro-patch, 0.2mg/hr, Norvasc, 10mg, o.d. 2007 Altace (ACE Inhibitor like Vasotec) 5mg, o.d. • Frequent, excruciating headaches B.P. 136/75 2009 Hydro-Clorothiazide (is a Sulphonamide) 25mg ,o.d. • Severe stomach pain • Nausea • Constipation B.P. 127/73; was also on Atenolol 50mg, Norvasc, 10mg, & Vasotec 5mg. But discontinued due to stomach pain; Also, contra-indicated for diabetics 2012 Indapamide (is a Sulphonamide) 1.25mg ,o.d. • Strong sweet urine odor B.P. 137/83 but contraindicated for diabetics 2012 Nitro-patch (nitroglycerin) .2mg/hr for 12 hrs • Seizure • Blurred vision • Headache • Sweats • Nausea Had seizure within the first 12 hours 2013 Diltiazem (like Norvasc, calcium channel blocker) 120mg,o.d. • Tiny red spots/rash on left-side of face from nose down to chin • Extreme aggression • Mania • Extreme fatigue • Lack of appetite B.P. 178/108 (medication ineffectual) 2013 Metoprolol (like Atenolol) 25mg, b.i.d. • Lots of diarrhea (and daily) B.P. 165/100 (medication ineffectual) 2013 Clonidine (has Anticholinergic-like activity) .1mg, o.d. • Hallucinations, irritability B.P. 180/100 (medication ineffectual) I await your reply again and thank you kindly. Regards, XXXX

Hello again, Dr. Mittal, I guess this is my last allowed submission; I believe this site allows up to 2 follow-up questions. In reply to your suggestions-- Re. ARB's, you're right we haven't tried them; at least I think so because I have no record of trying them. I guess, when our family docter mentioned ARB's a few months ago, I was afraid my mother would have same experience as the Altace, excrutiating headaches, so I declined. What dose would you recommend to start? And, which other drug to eliminate, if any? The Vasotec? Lastly, in what combination of other antihypertensive meds and their dosages, would you recommend? To keep the Atenolol and Norvasc as you said were fine? If so, at what dosages? Re. CCB's, we're at the maximum dose right now with the Norvasc at 10mg; and so we tried the Diltiazem but that gave her a rash. Re. BB's, before the Spironolactone, we were using the maximum of Atenolol @ 100mg in conjunction w/ Vasotec @ 7.5mg and Norvasc @ 10mg. Her BP was 178/100 on average with all these. With the Spironolactone @ 12.5mg, given @ noon, Atenolol, given in the AM, was reduced to 50mg (from 100mg), Vasotec, given HS, was reduced to 5mg (from 7.5mg) and Norvasc, given at bed, remained @ 10mg, her resting BP, first thing in the morning before any meds, is 150/71 and 156/84, which is relatively O.K; however, as I said, her mood swings, aggression, confusion, tiredness, asking me to end her life, have been way out-of-control these days, adding that we, my mom's caregivers and I, who are experienced with her dementia bouts are stunned at her behaviour these days. I don't have any recent blood and urine results than the ones below. Hopefully it helps you. Aug 2012 General Chemistry Hemoglobin A1C Hemoglobin A1C A 6.1 4.5-6.0 % The CDA recommends measuring Hemoglobin A1C every three months in all diabetics. Target: <7 % Measurement for screening purposes is not recommended. Sodium 140 134-145 mmol/L Potassium 3.9 3.5-5.0 mmol/L Uric Acid A 575 172-458 umol/L Miscellaneous Chemistry Serum Indices Lipemia A Slight Dec 2012 Hematology WBC A 13.6 4.0-10.0 giga/L RBC 4.52 3.80-4.80 tera/L Hemoglobin 124 120-150 g/L Hematocrit 0.36 0.35-0.43 MCV A 81 82-98 fl MCH A 27.4 27.5-33.5 pg MCHC 341 305-365 g/L RDW A 14.8 11.5-14.5 % Platelet Count 276 150-400 giga/L Differential Neutrophils A 10.6 2.0-7.5 giga/L Lymphocytes 2.0 1.0-4.0 giga/L Monocytes 0.8 0.1-0.8 giga/L Eosinophils 0.2 0.0-0.7 giga/L Basophils 0.1 0.0-0.2 giga/L General Chemistry Hemoglobin A1C Hemoglobin A1C A 6.6 4.5-6.0 % The CDA recommends measuring Hemoglobin A1C every three months in all diabetics. Target: <7 % Measurement for screening purposes is not recommended. Creatinine 59 50-100 umol/L Estimated GFR 85 >=60 mL/min Urinalysis Urine Chemistry Colour YELLOW Appearance CLEAR pH 7.5 5.0-8.5 Specific Gravity 1.012 1.003-1.035 Protein A 1 <0.15 g/L Glucose <3 <3 mmol/L Ketones <1.5 <1.5 mmol/L Hemoglobin <0.6 <0.6 mg/L Nitrite NEG Neg Leukocytes <25 <25 Leu/uL Thank you, again, very much for your time and thoughts, Dr. Mittal. It was a pleasure to confide in you. Best of luck to you as well. Regards, XXXX

Oops, omitted to give you my mother's pulse rates, yesterday morning was 64 and this morning was 68.