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Q: How would you evaluate the risk for edema in MP?
A: Before you prescribe a TZD for MP, you should evaluate her risk for CHF (Table 1).1 The AHA/ADA guideline recommends the following steps before starting a TZD in patients with diabetes:
- Ascertain whether the patient has any underlying cardiac disease.
- Note whether the patient is taking any drugs associated with fluid retention (Table 2).
- Evaluate pathogenesis of any preexisting edema to be sure CHF is not present (edema not caused by CHF is not a contraindication for TZD use; however, edema should be monitored carefully in such cases).
- Evaluate for any shortness of breath that might be due to other causes (asthma, chronic obstructive pulmonary disease, obesity) to determine baseline symptoms.
- Review most recent electrocardiogram for left ventricular hypertrophy or a clinically silent MI. (In this case, since MP has had a previous MI, we would expect to see evidence of this.)
- Instruct patient to report any new sign or symptom (weight gain >3 kg, pedal edema, shortness of breath, fatigue without apparent cause).
In patients like MP who have one or more risk factors for CHF (see Table 1) but without signs and symptoms of CHF (Table 3), a TZD may be started with low-dose (2 mg/d to 4 mg/d rosiglitazone or 15 mg/d pioglitazone) TZD. The dose can be increased gradually as required, and MP should be observed for any signs of excessive weight gain, peripheral edema, or CHF.
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