Timolol 10mg / Amiloride 2.5mg / Hydrochlorothiazide 25mg tablets

BackgroundHypertension (HT) prevalence, Uncontrolled Blood Pressure (UBP), morbidity and mortality are highest in Sub-Saharan Africa (SSA). Correlating pathophysiology of HT to pharmaco-therapy with antihypertensive drugs (AHD) may bring amelioration. Aims:To review peculiarities of HT in SSA, UBP causes, diagnostic modalities, AHD use, rationality and efficacy.Methods and results14 published therapeutic audits in 4 SSA nations on Google Scholar or PUBMED, (total n = 6496 patients) were evaluated. Calcium Channel blockers (CCB) amlodipine, and thiazide diuretics (TD), hydrochlorothiazide (HCTZ) were the commonest AHD. Thiazide Like Diuretics (TLD) were underutilized. The % of patients on AHD were: 1 drug 5.4-55%; 2 drugs 37-82%; >/ = 3 drugs 6-50.3%. 2-drug combinations were: ACEI/ARB + TD (42%); CCB + TD (36.8%); ACEI + CCB (15.8%) of studies. Triple/quadruple therapy included Methyldopa (MTD) with ACEI + CCB or TD. The (%) attaining BP ConclusionsTherapeutic inertia; Non-compliance; co-morbidities; refractory HT; ignorance; substandard AHD; contribute to UBP. Studies relating 24 hour ABPM to complications and mortality in SSA hypertensives; and impact of different AHD classes on ABPM, are needed. Study of ACEI + alpha-1 blockers + TLD on 24 hour ABPM and personalized care, are required.

Abstract licence: CC BY-NC-ND

Abstract Introduction Arginine vasopressin resistance (AVP-R), previously called nephrogenic diabetes insipidus, is a well-recognized complication of long-term lithium therapy. It results from impaired renal response to arginine vasopressin, leading to excessive polyuria and compensatory polydipsia. Although most patients maintain normal serum sodium through intact thirst mechanisms, AVP-R can significantly affect quality of life. When thirst is impaired or water access is restricted, moderate to severe hypernatremia may develop. Case report A 57-year-old woman diagnosed with bipolar affective disorder, treated with lithium and carbamazepine since adolescence, was referred to Endocrinology with a one-year history of polyuria and polydipsia. She reported partial symptom relief following a reduction in lithium dosage by her psychiatrist. Initial evaluation showed a 24-hour urine output of 3250 mL, urinary sodium of 78 mEq/day (40-220) and urine osmolality of 134 mOsm/kg. Serum analysis without fluid restriction showed normal renal function and electrolytes (Na 143 mmol/L [135-147], K 4.5 mmol/L [3.5-5.1],), plasma osmolality of 300 mOsm/kg (282-300) and normal glycated hemoglobin and corrected total calcium levels. Overnight water restriction revealed plasma sodium of 145 mmol/L, plasma osmolality of 307 mOsm/kg, and urine osmolality of 232 mOsm/kg. The patient underwent an inpatient water restriction test which supported the diagnosis of complete AVP-R and excluded both primary polydipsia and AVP deficiency. Pre- desmopressin measurements showed plasma sodium of 148 mmol/L, plasma osmolality of 315 mOsm/kg, and urine osmolality of 302 mOsm/kg. At 30 minutes post-desmopressin, urine osmolality was 191 mOsm/kg, further data were considered unreliable due to inadvertent fluid intake. Given the likely lithium-induced etiology, treatment with hydrochlorothiazide 50 mg and amiloride 5 mg daily was initiated. Over two months, the patient reported a marked reduction in polyuria and polydipsia. Follow-up tests demonstrated plasma sodium of 137 mmol/L, plasma osmolality of 292 mOsm/kg, and an improved urinary osmolality of 265 mOsm/kg. Conclusion This case highlights the challenge of lithium-induced AVP-R and the benefit of treatment with hydrochlorothiazide and amiloride. Symptoms are often underestimated and misattributed to primary polydipsia, partly due to mental health stigma. Clinicians should be alert to AVP-R in patients on long-term lithium, with water restriction testing being key for diagnosis.

Abstract licence: CC BY-NC 4.0