Micardis (Telmisartan)

[GreenMachineX]

How many people are using this? I’ve been on losartan for 6 months but my ALT is slightly elevated so I’ll be switching to telmisartan for its various benefits.

I’m mostly curious how intense the risk of hyperkalemia is with this drug? I’m only prescribed 20mg to start but want to make sure no issues arise as I do like potassium rich foods. I haven’t had a significant problem with losartan yet, but my potassium went from 3.9 to 4.5 just from getting off a keto diet while on losartan. I’m concerned it’ll keep going up. Anyone have any thoughts?

 

[2kvette]

How many people are using this? I’ve been on losartan for 6 months but my ALT is slightly elevated so I’ll be switching to telmisartan for its various benefits.

I’m mostly curious how intense the risk of hyperkalemia is with this drug? I’m only prescribed 20mg to start but want to make sure no issues arise as I do like potassium rich foods. I haven’t had a significant problem with losartan yet, but my potassium went from 3.9 to 4.5 just from getting off a keto diet while on losartan. I’m concerned it’ll keep going up. Anyone have any thoughts?

Pharm student here. Telmisartan is a touch stronger; I would advise you watch it & request your PCP to draw a CMP panel. My father just got out of the hospital for an arrhythmia d/t hypokalemia after his PCP "forgot" to draw his after starting him on HCTZ. Potassium is what we inject stratight into the heart to stop it when doing heart transplants. It increases the time it takes the ventricles to repolarize b/t contractions. So watch out for any chest pain or palpitations and limit your potassium intake. Drinking more water may help as well; higher blood volume means your kidneys have to pull in more sodium to maintain osmolality. For them to do this potassium must be excreted.

Im surprised he didnt add some HCTZ to your meds to balance the potassium out.

 

[hamdysayed]

I used it my last cycle and bp always stayed in range.
I ran 40 mg with no issue

 

[GreenMachineX]

I used it my last cycle and bp always stayed in range.
I ran 40 mg with no issue

No concern with hyperkalemia?

 

[hamdysayed]

No concern with hyperkalemia?

yeah there was times I can feel off but I ran it for 10 weeks and was good.
was watching out for potassium tho

 

[trn450]

Generally speaking, a stable K+ of 4.5 is not concerning. Stability can be demonstrated with a series of lab draws. I personally would not increase medical regimen complexity and an additional anti-hypertensive medication for such a purpose and would stick to just getting the BP into range. If the K+ were in the mid 5's or higher, that's a different story.

Drinking more water is unlikely to help. Clinically, the fluid balance tends to revolve around total body electrolyte content, and not the other way around. Recall the calculation we use to determine osmolarity = 2[Na+] + [Glucose]/18 + [ BUN ]/2.8 + [Ethanol]/3.7. Water isn't even in the equation. Any changes in the electrolyte concentration in the blood will likely be small and transient as the kidneys will likely just dump out the extra fluid; they can very easily process up to about ~16L/day. Fluid retention is attained when electrolytes are consumed concurrently. This is why we give saline solution in hypovolemic patients, and this is why we give pedialyte and similar concoctions to patients with diarrhea.

In general, my philosophy is to not over-think it. If your K+ is in range, stable, and your BP is well controlled don't start trying to micro-manage your prescriptions by adding more prescriptions. Medical regimen complexity is an independent risk factors for hospitalization and various types of morbidity (and probably mortality). It's not benign to start adding additional medications without a strong indication. If your BP isn't controlled and your K+ is near the upper limit of the reference range, then perhaps going with a thiazide diuretic (e.g. chlrothalidone) as opposed to a calcium channel blocker (such as amlodipine) is reasonable. But, at K+ of 4.5 wouldn't take me off of my standard algorithm of BP control, personally.

Of note, I have very limited information and this isn't advice. It's simple educational discussion.

 

[2kvette]

Generally speaking, a stable K+ of 4.5 is not concerning. Stability can be demonstrated with a series of lab draws. I personally would not increase medical regimen complexity and an additional anti-hypertensive medication for such a purpose and would stick to just getting the BP into range. If the K+ were in the mid 5's or higher, that's a different story.

Drinking more water is unlikely to help. Clinically, the fluid balance tends to revolve around total body electrolyte content, and not the other way around. Recall the calculation we use to determine osmolarity = 2[Na+] + [Glucose]/18 + [ BUN ]/2.8 + [Ethanol]/3.7. Water isn't even in the equation. Any changes in the electrolyte concentration in the blood will likely be small and transient as the kidneys will likely just dump out the extra fluid; they can very easily process up to about ~16L/day. Fluid retention is attained when electrolytes are consumed concurrently. This is why we give saline solution in hypovolemic patients, and this is why we give pedialyte and similar concoctions to patients with diarrhea.

In general, my philosophy is to not over-think it. If your K+ is in range, stable, and your BP is well controlled don't start trying to micro-manage your prescriptions by adding more prescriptions. Medical regimen complexity is an independent risk factors for hospitalization and various types of morbidity (and probably mortality). It's not benign to start adding additional medications without a strong indication. If your BP isn't controlled and your K+ is near the upper limit of the reference range, then perhaps going with a thiazide diuretic (e.g. chlrothalidone) as opposed to a calcium channel blocker (such as amlodipine) is reasonable. But, at K+ of 4.5 wouldn't take me off of my standard algorithm of BP control, personally.

Of note, I have very limited information and this isn't advice. It's simple educational discussion.

It is in the equation, those are concentrations. As water volume increases, those numbers all go down. Amlodipine can't be given without a beta blocker. too much baroreceptor reflex.

 

[trn450]

It is in the equation, those are concentrations. As water volume increases, those numbers all go down. Amlodipine can't be given without a beta blocker. too much baroreceptor reflex.

The water critique is a acceptable as it's reasonable to be precise. You misunderstand how it actually works, but I do appreciate the need for precision in communication. I should have said that water is not a "variable" in the equation. And, as I said earlier, that's because the osmolarity is driven by those electrolytes and molecules. Not the other way around. If you'd like to challenge this further to support your claim above, show me where there exists a variable in that equation where you can add water to change the osmolarity.

Of course, in reality there are some exceptions. But, that alone would be a massive lecture. Suffice it to say, consumption of water is ineffective by itself for increasing blood volumes when not paired with an increase in blood electrolyte content. As you'll see, blood volume expansion is highly dependent on sodium, and other electrolytes and molecules included in the osmolarity equation; this is very old knowledge: Invalid Link Removed

As for the amlodipine comment, you don't seem to have the knowledge to understand what you're talking about. Beta blockers are effectively the 4th line agent in hypertension management unless there is some other medical comorbidity that would benefit from beta blockade. This means amlodipine is routinely, and safely, given in absence of beta blockade. You can see this for yourself in the JNC-8 guidelines: Invalid Link Removed

 

[2kvette]

The water critique is a acceptable as it's reasonable to be precise. You misunderstand how it actually works, but I do appreciate the need for precision in communication. I should have said that water is not a "variable" in the equation. And, as I said earlier, that's because the osmolarity is driven by those electrolytes and molecules. Not the other way around. If you'd like to challenge this further to support your claim above, show me where there exists a variable in that equation where you can add water to change the osmolarity.

Of course, in reality there are some exceptions. But, that alone would be a massive lecture. Suffice it to say, consumption of water is ineffective by itself for increasing blood volumes when not paired with an increase in blood electrolyte content. As you'll see, blood volume expansion is highly dependent on sodium, and other electrolytes and molecules included in the osmolarity equation; this is very old knowledge: Invalid Link Removed

As for the amlodipine comment, you don't seem to have the knowledge to understand what you're talking about. Beta blockers are effectively the 4th line agent in hypertension management unless there is some other medical comorbidity that would benefit from beta blockade. This means amlodipine is routinely, and safely, given in absence of beta blockade. You can see this for yourself in the JNC-8 guidelines: Invalid Link Removed

I just got out of cardiology last semester. JNC8 says that but it’s not going to have an effect on BP. Amlodipine dialates arteries. You get reflex tachycardia without a beta blocker. I add beta blockers to n-dhp CCB regimens daily.

 

[trn450]

I see... Cardiology what? What is your training background and which country?

This isn't just JNC-8, this is basically every blood pressure guideline available. If they're keeping the secret from internal medicine physicians like myself, I'd love to see the evidence. Additionally, the additional beta blocker absolutely has an impact on blood pressure. It will, of course, be dose dependent though.

 

[2kvette]

I see... Cardiology what? What is your training background and which country?

This isn't just JNC-8, this is basically every blood pressure guideline available. If they're keeping the secret from internal medicine physicians like myself, I'd love to see the evidence. Additionally, the additional beta blocker absolutely has an impact on blood pressure. It will, of course, be dose dependent though.

Background: AS General & Inorganic chemistry. BS Biological & medicinal chemistry, minor pharmaceutical chemistry. PharmD2(2/4years done) still in school for the last one.
In USA, I’ve been through AHA/ACC & JNC8 CPG’s. That’s all we’re taught from clinically.

Here is what we were taught. Non dhp CCB’s cause too much of a decrease in TPR to give without a beta blocker, so just don’t do it unless it’s CI. Also taught beta blockers have no significant effect on BP, which is why they’re last line.

 

[toddmuelheim]

Background: AS General & Inorganic chemistry. BS Biological & medicinal chemistry, minor pharmaceutical chemistry. PharmD2(2/4years done) still in school for the last one.
In USA, I’ve been through AHA/ACC & JNC8 CPG’s. That’s all we’re taught from clinically.

Here is what we were taught. Non dhp CCB’s cause too much of a decrease in TPR to give without a beta blocker, so just don’t do it unless it’s CI. Also taught beta blockers have no significant effect on BP, which is why they’re last line.

You’re making too many blanket statements. BB are not always last line. You aren’t walking out of a hospital after a CV event without a BB. There’s also certain demographics that respond particularly well to CCB, without the immediate need for combo therapy.

 

[Outofbody]

I used losartan for years and switched to Olmesartan when I needed something stronger. It's a bit more expensive with far fewer possible sides, although losartan has very little if any sides to begin with. Anyhow, I'm very happy with olmesartan, fwiw

 

[Outofbody]

Im surprised he didnt add some HCTZ to your meds to balance the potassium out.

There is a medication available that's a combination of Losartan + HCTZ. I forget what it's called, but I took it once, before switching to olmesartan myself. I tend to get dehydrated easily and I didn't like the idea of the addition of the water pill (HCTZ) possibly causing ED in the long run, which is why I switched to olmesartan.

 

[T3x]

Hyzaar

 

[trn450]

You’re making too many blanket statements. BB are not always last line. You aren’t walking out of a hospital after a CV event without a BB. There’s also certain demographics that respond particularly well to CCB, without the immediate need for combo therapy.

These are words from someone with clinical experience. What is your background?

 

[trn450]

Background: AS General & Inorganic chemistry. BS Biological & medicinal chemistry, minor pharmaceutical chemistry. PharmD2(2/4years done) still in school for the last one.
In USA, I’ve been through AHA/ACC & JNC8 CPG’s. That’s all we’re taught from clinically.

Here is what we were taught. Non dhp CCB’s cause too much of a decrease in TPR to give without a beta blocker, so just don’t do it unless it’s CI. Also taught beta blockers have no significant effect on BP, which is why they’re last line.

I see, the "pharm student here" guy. I remember now ^_^

I enjoy the enthusiasm. But, you're definitely learning incorrect information. As did I in medical school whenI was being taught by PhD's, etc. Arrogance is a trait that is not in short supply among professors, yet it's almost universally unproductive or worse.

Amlodipine is the only CCB I work with regularly in my practice as I am not a cardiologist. So, I'll keep my discussion to amlodipine. If there was some new movement to include BB in every patient on amlodipine, that's news to me. I'd also be exceedingly skeptical to implement unless there was a massive proven benefit in RCT's. All the guidelines suggest beta blockers down the line, by up to two drugs, from CCB's which means that necessarily CCB's are given without BB's according to those guidelines. BB's often make people feel like utter garbage and seems to provide less protection against stroke. So, there are other reasons than efficacy which determine the utility of the BB class in hypertension control. And amlodipine, even as a solo medication, are often tolerated exceptionally well with very potent anti-hypertensive activity with rare to few side effects. The only complaint I see is people who may have already had some degree of venous insufficiency getting additional edema. I'm not going to waste my time substantiating the safety and efficacy of a CCB like amlodipine as a first or second line agent in the management of hypertension. There is a literal overwhelming abundance of evidence to support that. You were not satisfied with JNC-8's algorithm, clearly. But, even Up To Date's take on choice of therapy does not pair CCB's with BB's as first line combination therapy.

Back to the point about arrogant PhD's spewing nonsense and beta blockers. Beta blockers absolutely do lower blood pressure. And, actually, an average of 9.8 mmHg (Table 3): Invalid Link Removed

We have a saying in medicine: "Trust nobody, expect sabotage". lol. In other words, accept the knowledge your professors give you, but be sure to challenge it.

 

[2kvette]

I see, the "pharm student here" guy. I remember now ^_^

I enjoy the enthusiasm. But, you're definitely learning incorrect information. As did I in medical school whenI was being taught by PhD's, etc. Arrogance is a trait that is not in short supply among professors, yet it's almost universally unproductive or worse.

Amlodipine is the only CCB I work with regularly in my practice as I am not a cardiologist. So, I'll keep my discussion to amlodipine. If there was some new movement to include BB in every patient on amlodipine, that's news to me. I'd also be exceedingly skeptical to implement unless there was a massive proven benefit in RCT's. All the guidelines suggest beta blockers down the line, by up to two drugs, from CCB's which means that necessarily CCB's are given without BB's according to those guidelines. BB's often make people feel like utter garbage and seems to provide less protection against stroke. So, there are other reasons than efficacy which determine the utility of the BB class in hypertension control. And amlodipine, even as a solo medication, are often tolerated exceptionally well with very potent anti-hypertensive activity with rare to few side effects. The only complaint I see is people who may have already had some degree of venous insufficiency getting additional edema. I'm not going to waste my time substantiating the safety and efficacy of a CCB like amlodipine as a first or second line agent in the management of hypertension. There is a literal overwhelming abundance of evidence to support that. You were not satisfied with JNC-8's algorithm, clearly. But, even Up To Date's take on choice of therapy does not pair CCB's with BB's as first line combination therapy.

Back to the point about arrogant PhD's spewing nonsense and beta blockers. Beta blockers absolutely do lower blood pressure. And, actually, an average of 9.8 mmHg (Table 3): Invalid Link Removed

We have a saying in medicine: "Trust nobody, expect sabotage". lol. In other words, accept the knowledge your professors give you, but be sure to challenge it.

You just blew my mind. They preached and preached this to us. Sometimes I’ll pick up something they say that I know is wrong. Like in diabetes lectures, this lady told me testosterone would raise A1C. I was like wtf?! She was adamant about it too. Basing her claim on increased insulin resistance in diabetics during puberty. She didn’t know it was from the GH surge, not the test.

 

[trn450]

You just blew my mind. They preached and preached this to us. Sometimes I’ll pick up something they say that I know is wrong. Like in diabetes lectures, this lady told me testosterone would raise A1C. I was like wtf?! She was adamant about it too. Basing her claim on increased insulin resistance in diabetics during puberty. She didn’t know it was from the GH surge, not the test.

Just like that scene were Neo wakes up in the Matrix, it's tough when you realize that even the professors you admire can be willfully ignorant morons despite being geniuses in other contexts. lol.

To be fair, it's not just professors. It's nearly all humans on effectively all topics. Its just that, at least to me, it's most disappointing coming from academics. I'm a fairly left-leaning liberal / libertarian who considers the scientific process and the pursuit for truth to be effectively holy. So, I'm dying on the inside as I watch academia fall in the west, rotting from the inside.

On that note, as long as you continue to honor your integrity and maintain truth as the highest (or at least one of the highest) virtues, you'll not disappoint people who look up to you in the future very often. ^_^ And, your patients will benefit greatly.