A 68-year-old man comes to the office due to recurrent episodes of dizziness. His medical problems include hypertension, coronary artery disease, asthma, type 2 diabetes mellitus, and hypercholesterolemia. He is retired and lives alone. He does not use tobacco, alcohol, or drugs. Medications include aspirin, enalapril, isosorbide mononitrate, simvastatin, glyburide, and metformin. Temperature is 36.7 C (98 F), blood pressure is 125/80 mm Hg in the decubitus position and 100/70 mm Hg in the standing position, pulse is 86/min in the decubitus position and 92/min in the standing position, and respirations are 14/min. Examination shows no abnormalities. Which of the following is the most effective strategy to manage this patient's symptoms?

Question

A 68-year-old man comes to the office due to recurrent episodes of dizziness.  His medical problems include hypertension, coronary artery disease, asthma, type 2 diabetes mellitus, and hypercholesterolemia.  He is retired and lives alone.  He does not use tobacco, alcohol, or drugs.  Medications include aspirin, enalapril, isosorbide mononitrate, simvastatin, glyburide, and metformin.  Temperature is 36.7 C (98 F), blood pressure is 125/80 mm Hg in the decubitus position and 100/70 mm Hg in the standing position, pulse is 86/min in the decubitus position and 92/min in the standing position, and respirations are 14/min.  Examination shows no abnormalities.  Which of the following is the most effective strategy to manage this patient's symptoms?

Quizplus · Accepted Answer

Explanation: Polypharmacy is defined as the use of multiple (generally ≥5) drugs in a single patient, typically to manage different medical conditions. Polypharmacy is common in the elderly. Knowledge of drug interactions and adverse effects is essential to the primary care provider. For instance, although beta blockers are usually included as part of the treatment of coronary artery disease, they were not prescribed to this patient, likely due to his diabetes and asthma. This patient takes the following medications: aspirin, enalapril, isosorbide mononitrate, simvastatin, glyburide, and metformin. He has orthostatic hypotension-given the significant drop in blood pressure (eg, systolic blood pressure drop >20 mm Hg) and increase in pulse when he moved from the decubitus to the standing position-associated with dizziness. These findings are classically associated with the use of diuretics, alpha blockers, or nitrates. Isosorbide mononitrate use has been associated with dizziness (in 4% of patients) and orthostatic hypotension (in 1% of patients). Therefore, it should be stopped in this patient. (Choice A) Enalapril is an antihypertensive drug that has not been associated with orthostatic hypotension as frequently as the drugs mentioned above. Side effects include renal failure, hyperkalemia, cough, and angioedema. (Choice C) Simvastatin can cause myalgias, rhabdomyolysis, and liver function test abnormalities. Its use is not associated with orthostatic hypotension. (Choice D) As the patient's findings are likely due to polypharmacy and he has no focal neurologic deficits, there is no need for further studies (eg, CT scan, MRI) or neurologic consultation. (Choice E) Meclizine may offer symptomatic benefit in cases of dizziness due to vestibular disease, not those associated with orthostatic hypotension. Educational objective: Polypharmacy is frequent in the elderly. Orthostatic hypotension is common in this setting and is usually related to the use of diuretics, alpha blockers, or nitrates.

A 68-Year-Old Man Comes to the Office Due to Recurrent