His condition when I met him was alarming. Six weeks before he had been fully functional and working. He had been referred for poorly controlled hypertension, but as I was meeting him, that was the least of his problems. Both feet were blood red up to just above the ankle, swollen, and extremely painful. He had not walked or worked in a month. Six weeks before, his blood pressure was poorly controlled. He was on amlodipine at the time which caused ankle swelling, and so his doctor stopped that drug. Without amlodipine the blood pressure level went even higher and his doctor started minoxidil which can cause fluid retention and swelling of the legs. It also causes a rapid heartbeat, so high doses of fluid pills were added to get rid of the fluid and propranolol, a beta blocker to slow the heart. Clonidine was also added to help with the blood pressure. Despite all this effort, his blood pressure remained high.
His lab work had been pretty normal 6 weeks before, but his new labs that I ordered urgently were way off. His kidney function had fallen from normal to about forty percent of normal. He was very dehydrated because of his fluid pills. He had the highest uric acid level that I ever encountered. So, his red legs were due to the worst case of gout that I had ever seen. Uric acid forms uric acid crystals in the joints and that causes severe inflammation, arthritis, and pain. Most people just have gout in the first joint of the big toe. It hurts so bad, that people with this disease don’t even like the weight of the sheets on that joint when they are in bed. He came to me for blood pressure management, but that was not his greatest concern. His gout was the first priority. He wanted to get rid of the pain and go back to work.
The first order of business was to begin backing off minoxidil and the fluid pills. I also gave him allopurinol to lower his uric acid. Then I needed to figure out what had gone wrong. That became clear right away. Swelling from amlodipine is not dangerous, and if you give it with a drug like lisinopril or losartan, that solves the swelling problem. I started him back on amlodipine, and as his kidney function improved, I added a small dose of losartan. I tapered off minoxidil, the heavy doses of diuretics, propranolol, and clonidine while substituting the drugs on our high blood pressure protocol—losartan or lisinopril, amlodipine, a thiazide diuretic, and eplerenone or spironolactone if needed.
Within a couple of weeks, this man had good blood pressure control, the pain in his feet was gone, and he was back at work. Almost half of Amercan adults have high blood pressure. It is the leading reason that adults see a primary care clinician. Controlling high blood pressure is the easiest thing we can do with the most impact on preventing heart attacks and strokes. Despite the enormous importance of getting high blood pressure right, only 44% of Americans with high blood pressure are controlled to a goal of 140/90. Organizations that use protocols and teams have hypertension control rates of 90% with much less likelihood of a side effect catastrophe like this. Rural communities and disadvantaged neighborhoods can have excellent treatment for high blood pressure. The first step is to know the percentage of people in your community who have their blood pressure controlled. Be sure your community has the best approach to this common problem.
Your comment about blood pressure is very interesting as last year, my blood pressure was fine stopped by the doctor for an appointment and on a whim got a blood pressure test and it turned out to be skyhigh. I’m on medicine and it’s now under control but it’s shocking how fast it changed.
He was lucky to have found you. Were the original treating doctors so incompetent they didn't see the changes and do something different? How do you know which ones to trust?