rxpertusa logo spacer rxpertusa wings
logo spacer spacer spacer
spacer home
about us
assessment tools
sample consult
contact us
favorite links

red line

spacer spacer news

The latest Mainline newsletters for the General Public are listed here.


For healthcare professionals we have a Mainline newsletter in a Professional version here.



Links to other Consults on our site

Consult 1

Consult 2

Consult 3

Consult 4

Consult 6

Consult 7

Consult 8

Need Drug info (free) use our contact us feature

leave your e-mail or phone and name


                                 Medication Therapy Management Services

                       440 North Second St., P.O. Box 1288, Eunice, LA 70535

                  Phone (337) 457-4604 Fax (337) 546-0900 Cell (337) 344-2297

                       Charles S. Feucht,PD,FASCP Senior Care Clinical Pharmacist


Patient Profile for: Mr Mxxx Sxxxxx 

Personal Information

Patient ID:                  #602006

Attending Physician:              xxxxxxxx,MD

Patient Name:          xxxx xxxxxxx

Address:                     xxxxxx.

City:                       Crowley

State:                                        LA

Zipcode:                     70526

Country:                     USA

Phone:                        xxx xxx xxxx

Fax:                            xxx xxx xxxx ____________________________________________________________________________ 

Medical Information ____________________________________________________________________________ 

Diagnosis: None provided: suspected from current drug therapy

              Type II diabetes mellitus





General complaints not listed as diagnosis by your doctor:

Weak spells NOS when blood sugar drops – frequency not provided time of events not provided
Feet swell daily and painful right side swells more than left
1 fall this past year
Sporadic complaints of heartburn

Allergies:  ?

 Dosing considerations:

 Renal impairment ( assessment made by this reviewer from estimated creatinine

                      clearance  calculation based on serum creatinine of 1.5 obtained 4/18/2006.) CrCl =


Gender:                      Male

DOB:                       November 27, 1919        Age: 86

Height:                                    70" ( 175cm)

Serum Creatinine:     1.5mg/dl    Date:4/18/2006

Estimated Creatinine Clearance:  34.1ml/min



Laboratory Values:

Lipid Panel

        Triglycerides                                 126                      5-22-06

        Total cholesterol                           148              5-22-06

        HDL cholesterol                             39 low                  5-22-06

        LDL-Cholesterol                            84                        5-22-06

        Chl/hdl ratio                                 6.1                       5-22-06

Protime INR                                          2.5                       5-22-06

              Microalbumin urine                                     101                      4-18-06                          

              Complete Metabolic Profile:

                            BUN                                           28                         4-18-06                          

                            Creatinine                                   1.5                       4-18-06                          

                            BUN/Cr                                        19                       4-18-06                          

                            Sodium                                       139                      4-18-06                          

                            Potassium                                   4.1                       4-18-06                          

                            Chloride                                      103                      4-18-06                          

                            CO2                                             2                        4-18-06                          

                            Calcium                                      9.4                       4-18-06                          

                            Protein, Total                              6.5                        4-18-06                          

                            Albumin                                     4.1                        4-18-06                          

                            Globulin                                     2.4                        4-18-06                          

                            Alb/glob                                     1.7                        4-18-06                          

                            Bilirubin, total                             0.6                        4-18-06                          

                            AKPhos                                      80                         4-18-06                          

                            AST                                           20                         4-18-06                            

                            ALT                                                  16                   4-18-06                          

              CBC      Within normal limits 4-22-06                                                

              PSA                                                               5.0                  4-22-06            

              T-3 & T4 within normal limits no TSH available


Furosemide 40mg 1 tablet by mouth daily

Celebrex 200mg 1 capsule by mouth daily

Klor-con 10mEq 1 tablet by mouth daily

Levoxyl 100mcg 1 tablet by mouth before meal daily

Insulin  glargine(Lantus)  65units sc daily

Lotensin 10-12.5 1 tablet by mouth daily

Coumadin 5mg 1 tablet by mouth on Sunday, Tuesday, & Wednesday

                              1 ½ tablets by mouth on Monday & Friday

Allopurinol 300mg 1 tablet daily for gout

Actos 45mg 1 tablet by mouth daily



June 27, 2006

Pharmacology Review and recommendations:

Initial review & assessment

The patient is an 86 year old white male. The history provided is sparse. The main complaint is that of painful and edematous feet particular the right side. This assessment is made based on a very limited history, the current complaints, current drug regimen and limited lab values. Ideally, hemoglobin A1C levels along with at least two weeks of blood pressure readings and fingerstick plasma glucose levels would provide more insight for specific recommendations.

              Thiazolididiones such as the Actos you are taking are known to cause  fluid retention. Generally in elderly patients, doses should be less than 45mg daily if used in combination with insulin to prevent aggravation of congestive heart failure or retention of fluid. This fluid retention can be especially problematic when combined with insulin. It isn’t clear if you are taking the Lasix for congestive heart failure or if your furosemide is being used for edema problems. Avandia is another drug in this class of diabetic medications but it is not a viable alternative. Avandia  is also a thiazolidindione drug like Actos and carries the same potential to induce fluid retention. Other alternatives for combination oral hypoglycemic agents(agents that lower your blood sugar and are taken by mouth) such as metformin (Glucophage)  in conjunction with insulin have been used and resulted in very good control. However, due to your kidney function the drug  metformin should not be used.  The only remaining alternative oral hypoglycemic and insulin therapy combination would be to use a drug from the class known as secretagogues. Glyburide, Nateglinide, glipizide or glimiperide in combination with the basal insulin, Lantus, you are now taking would be an alternative. If you can log your fasting blood glucose levels which you test using your home meter and provide those I can make more specific dosage recommendations. Hemoglobin A1C levels should be monitored every 3 months to determine the level of  diabetes control you are achieving and would also be helpful in desiging a plan for control of your blood sugars.


The Lasix(furosemide) you are taking has a short half life. Torsemide(Demadex) is more favorably suited for you because of the following reasons:

  • On a weight to weight basis torsemide is twice as potent as furosemide
  • It provides a longer duration of action at lower urinary concentrations. This allows for a 24-hour dosage interval and avoids the paradoxical antidiuresis seen with Lasix . Torsemide doses of 10-20 mg are roughly equivalent to 40 mg furosemide
  • Data suggest torsemide exhibits less pronounced effects on the excretion of calcium, magnesium, and potassium than furosemide. This is important in your case as long term thyroid hormone supplementation n increases the risk for osteoporosis even in males and less wasting of calcium is important since your are on medication for hypothyroidism.
  • torsemide, has shown minimal effects on sodium and potassium however, at higher doses, these distinctions may be insignificant.
  • Reports of hyperuricemia (gout) were seen in clinical trials with furosemide, Torsemide was superior to these agents with no or slight increases in uric acid levels following administration during clinical trials.  This is especially important in your case since you have gout and are on prevention medication( allopurinol, Zyloprim).
  • Torsemide is effective in the treatment of mild to moderate essential hypertension.  Furosemide is not known to be as effective as thiazides or torsemide for blood pressure control. Changing from furosemide(Lasix)  40mg daily to torsemide(Demadex 10mg) daily will reduce the risk for aggravating your gout may, allow you to discontinue your potassium supplementation at some near time in the future and will prevent any rebound effects which can be seen with Lasix needing higher doses of both Lasix and potassium.

Suggestions to review with your physician:


  • Discontinue Lasix (furosemide) 40mg 1 tablet daily
  • Start Demadex (torsemide) 20mg 1 tablet by mouth daily.


    • Benazepril/HCTZ (Lotensin) 10-12.5mg 1 tablet  by mouth daily is borderline for continued use due to your kidney function.  Monitor for now provide RxPERTUSA with an updated weight and I will calculate your kidney function again and take a closer look as to whether or not this drug should be changed to only benazepril rather than the combination with HCTZ.


  • Discontinue Actos and start Amaryl 2mg 1 tab by mouth daily titrate dose upwards  to patient response.


  • Ask your physician about a glycohemoglobin test now and in 3 months, forward the results to RxPERTUSA
  • Ask  your physician about TSH level now forward the results to RxPERTUSA
  • Monitor your blood glucose in the morning before eating for two weeks and forward the results to RxPERTUSA for further review.
  • Monitor blood pressure daily in the morning and evening for two weeks and forward the results to RxPERTUSA for further review.



Thank you for this consult

Chalres S. Feucht,PD,FASCP. PharmD(cand)















Home ] [ About Us  ] [ Assessment Tools  ] [ Sample Consult  ]
Contact Us  ] [ Favorite Links  ]

Copyright © www.rxpertusa.com. Designed by PcHousekeeping.com
  spacer spacer