A patient with high blood pressure presented to my office with a severe headache. She has a history of seasonal allergies. The patient is adherent to her medication regimen. In the office, her blood pressure was 210/120. Normally, her blood pressure on therapy is 125/78. What is happening and what should we do?

It turns out the patient was outside with her family watching fireworks. Her allergies to pollen acted up, and she took pseudoephedrine to help control her symptoms. A side effect of this medication is hypertension.

I see a referral population which can be very different from the general population that sees a primary care practitioner. That said, I have seen many high blood pressure patients on allergy medications that have had bad outcomes: stroke, heart attack, kidney problems, and malignant (life-threatening) hypertension.

Both perennial and seasonal allergies can be annoying for a person. Its usually easy to tell an untreated patient with allergies because they give you the "allergic salute" (people with allergic rhinitis often rubs their noses using the index finger).

Many over the counter therapies for allergic rhinitis can worsen a patient's hypertension. For instance, phenylephrine, the active ingredient in Sudafed, can also increase a person's blood pressure. In fact, most decongestants (drugs that shrink the swollen membranes in the nose) may cause hypertension.

The best therapy for allergies in a patient with high blood pressure is an intra-nasal steroid. Avoidance of the allergens, if possible, also helps.

A cost-effective, generic nasal steroid that is not absorbed by the body is called fluticasone propionate which is currently $60 dollars a month at drugstore.com. Other steroid inhalers are available, but these can get very pricey.

There are other medication options for those on an extremely tight budget. The Walmart $4 list includes loratadine, which you can obtain via a prescription from your doctor. The medicine is generic and is the same thing as over the counter Claritin. This medicine is extremely effective and is a great second-line or add on therapy to the intranasal corticosteroid.

For those of you with hypertension and allergies who wish to try an over the counter nasal inhaler option, cromolyn sodium is available. Cromolyn stabilizes inflammatory cells which are involved in the allergy process. This medicine works. It is cost effective (around 12 dollars per inhaler), but the big downside here is that a person has to use it 4 times daily. I have found that many people are non-adherent to more than twice a day medication regimens. And if you don't take the medication it won't work. Therefore, Cromolyn is my third line therapy.

For those who do not like to take medication, nasal irrigation and saline sprays can be effective. Many of my patients find this form of therapy to be unappealing and give up on it quickly.

For the patient described here in the clinical vignette, I referred her back to her primary care physician for an allergy therapy assessment. I asked the patient to stop taking the pseudoephedrine and continue her current blood pressure medication therapy. Her blood pressure quickly returned to normal and with the help of her PCP (primary care physician), her allergies got better!

Every day, delivery of medical care becomes more streamlined and transparent. Alegent Nephrology is always making procedural adjustments to improve care and give you, a consumer of health care, the greatest return on your investment. As a center of excellence, where the highest standard of health care delivery and the highest quality of care in the region is, we want to make your visit as productive as possible.

Doctors, both generalists and specialists, have constraints on their time. New practices and new approaches need to happen in order to maximize everyone's time. In addition to bringing your co-payment, you should "invest" in the visit and do your part, so that by the time the visit has ended, a SUCCESSFUL plan of care is developed.

Here are some helpful tips to make the most of your medical appointments:

1. Ask questions. The relationship between you and your doctor is a special one based on trust and mutual respect. It is important to ask questions that concern you -- up front. It is normal to feel uncomfortable about discussing certain topics such as antibiotics after sexual intercourse. However, if you don't tell me, I can't help you.
2. Successful planning begins at home. Bring important records with you which should include your recent laboratory test results, a current list of your present and past diagnoses, and a current medication list based on the medicines you are presently taking and how often you take your pills. Every piece of information is a clue to making a diagnosis. For instance, as a kidney specialist, it makes a difference to me if you are taking Lasix once or twice a day.
3. Repetition is a good thing. Sometimes patients get annoyed that they have to repeat information. For clarity, I like it. Although the nurse may take your current medication list for the chart, I like to see what you are taking. Bringing an up to date list saves both you and me valuable time because I can read quickly.
4. Bring your records to the appointment. What if the electronic medical record is down? What if we can't find your chart? What if you see a doctor in a different system? Although exceedingly rare, problems do occur. Google Health, a flash drive with records, or paper speeds up the process. Then you don't have to wait for "old records" to be faxed to the clinic. Not infrequently I hear, "They told me they were going to send the records." Although people's intentions are good, sometimes records do not get sent by the time of the appointment.
5. Keep a list of your over the counter medications, alternative therapies, and vitamins. Some of these medicines interact with prescription medication, and these interactions can adversely affect therapy. For example, there is a known interaction between warfarin (coumadin) and cranberry juice that can affect INR (blood thinning) levels. Your doctor needs to know how you are treating particular conditions such as the prevention of urinary tract infection.
6. Know the physicians you see and why you see them. "Dr. Aaronson, the nephrologist, treats my blood pressure. Dr. Van De Graaff, the cardiologist, treats my heart failure and put in my pacemaker. Dr. Schwartz, the internist, treats my high cholesterol." Why is this tip so important? Dr. Schwartz may assume that Dr. Van De Graaf is treating high cholesterol. Dr. Van De Graaf may assume that Dr. Schwartz is treating high cholesterol. And the end result is nobody is treating the high cholesterol! By defining who takes care of which problem, nothing inadvertently gets missed.  Also, please remember to ask for a business card. Consider bringing these cards with you to every visit.
7. If you think it will be helpful, bring along a family member. Friends are also welcome. Accompanied by friends and family, you can have advocates present to help you understand what the doctor said or write down key points learned at the visit.
8. Make sure you understand what happens next. When will you see the doctor next? When does a blood draw need to happen? Also, make sure there is a mechanism in place so that if your symptoms worsen or don't improve you can get help. Emergency room visits or hospitalizations can be prevented!
9. Understand the language. "Doctor-speak" is foreign to most consumers of healthcare. These words are important however because that's how providers communicate with one another. You need to know the words and what they mean. I'm not asking you to memorize a medical dictionary, just the words used to describe the conditions you have. My job is to help explain what those words mean. I frequently write the patient's diagnosis on a piece of paper and provide a description of what that means. Feel free to look up the terms on the internet to learn more or ask me if you don't understand what I'm talking about! In the event you can't remember your diagnoses, make sure you always have an updated list with you so that your provider can take great care of you.

Remember, we all must work as a team to help make the medical visit productive and valuable. Communication is the key to getting value from your medical appointment. Mutual understanding and shared decision making helps you adhere to the medical plan and helps me give you world class care.

Over the years, I have helped scores of women with frequent, recurring urinary tract infections (UTIs). Since many recommendations have changed over the last decade, I decided to answer the question right away. Because some common practices have turned out to be unhelpful, an update is timely and warranted.

First, involvement of your primary care provider is critical. "Must not miss" disorders need to be considered prior to going forward with the recommendations given below.

Second, how do you define recurrent urinary tract infection? Most define recurrent UTI as when a woman has two or more symptomatic urinary tract infections in six months or three or more symptomatic UTIs over 12 months. What makes this definition less precise is the fact that the degree of discomfort in the woman usually is the determining factor that leads her to present to her primary care provider. Frustration usually motivates the woman to act.

Once your primary provider has determined you have recurring UTI's, the following recommendations may be made for young, healthy, non-pregnant women:

For sexually active women:

• If spermicides or diphragms are used, an alternative form of contraception may be recommended.
• Drinking fluid and urinating after sexual intercourse: studies have not proven the effectiveness of this strategy. Although some providers opine that this "doesn't hurt," my opinion is that if it doesn't help, why do it?
• Antibiotics are highly effective. There are many ways to effectively use antibiotics to prevent recurrent urinary tract infections (see below).
• Cranberry juice and concentrated cranberry extract tablets have not been proven to be effective. In my opinion, the cost, the calories, and the unpalatable taste make other alternatives desirable.

Antibiotic regimens:

• Low dose antibiotics daily
• Low dose antibiotics three times a week
• Antibiotics after sexual intercourse
• Alternatively, at the first sign of a urinary tract infection, when you first notice symptoms, an antibiotic is taken.
  

Studies have suggested these methods are efficacious for six months up to several years of therapy.

Questions:

1. Does the type of antibiotic prescribed make a difference? It turns out that all antibiotics are equally effective. Some antibiotics have to be dosed for kidney disease. Antibiotics can have side effects including diarrhea and yeast infections. That's why your primary provider is there to give you advice.
2. Do I have to worry about drug resistance? Yes, however it turns out that drug resistance is rare in this setting. Sometimes a urine culture is needed to see if the antibiotics are treating the organism causing the infection.

So that is the latest information on the treatment of recurrent urinary tract infections. If you have a follow up question or comment, please feel free to ask.

Dr. Eric Van De Graaff, Cardiologist at Alegent Health Clinic Heart and Vascular Specialists, wrote a very poignant article in defense of statins. His timing was perfect. It's almost as if he knew the Archives of Internal Medicine's June 28th article was going to be published.

You will be hearing a lot about this article: Statins and All-Cause Mortality in High-Risk Primary Prevention. The argument the study makes is that there may be little benefit in primary prevention patients to justify using statin medicines to lower your cholesterol level. (Primary prevention is defined as avoiding the development of a disease. Most population-based health promotion activities are primary preventive measures.) Before you stop your Lipitor, please consider Professor Van De Graaff's article in addition to mine where I "ditto" his argument.

Although diet and exercise are paramount, one can argue that protection through medication should be considered in patients at risk for dying from heart disease — if medication is indeed effective.

It takes time for atherosclerosis (plaque build-up) in the coronary arteries to become clinically evident heart disease. Trials that are stopped after only 4 years may not show a benefit because it may take many more years for the plaque build-up to result in a cardiac event (a heart attack). This is the definition of a false negative study: failure to detect a difference when a difference does in fact exist.

Let's use a simple country nephrology analogy. Take 2 cars in good condition. Drive up to Northern Minnesota. Rust-proof one car but leave the other alone. Drive the 2 cars during the winter, allowing the salty roads to attempt to rust the cars. After the first few years, we may be unable to detect a difference. However, after 5-10 years, the rust proofing shows a benefit whereas the other did not. People are not cars; however, a high salt, fatty diet resulting in obesity can lead to heart disease over time. Perhaps we didn't perform due diligence and give enough time to allow a difference to happen because it takes many years for fatty material to deposit in a vessel wall:

The problem with primary prevention trials is that they require too much time and are extremely expensive. Pharmaceutical companies don't want to pay because of drug patent-life issues and decreased return on investment. Therefore, the National Institute of Health needs to fund this study. The problem however, is who wants to wait a generation to find out the results when you could be benefiting right now?

Fortunately we have many good 4 dollar a month medicines. For now, in a high risk population, I would opine that we should consider using cost effective statin drugs. This may be a leap of faith, but until proven otherwise, the mechanism of action makes sense. Given the billions of dollars Americans waste on vitamins, it could be argued they would be willing to pay for the proposed benefit. Moreover, if a generic statin is not powerful enough, you might want to consider a more powerful statin, like Lipitor. That choice is between you and your clinician.

Finally, there is no question that patients who already have established heart disease should be on a statin because these cholesterol lowering medications prevent death from heart disease and complications related to heart disease. This is called secondary prevention.

So let's say that you are a purest and want to wait until you have absolute evidence of cardiovascular disease. The question now becomes when to intervene. When does a stable heart plaque become unstable? Are our current markers adequate to know when to start statins? Do you want to wait until you have a heart attack prior to starting the medication? Determining whether you have heart disease or not is a challenge, one I will defer to Alegent Health Clinic Heart and Vascular Specialists and the primary care docs. However, in my opinion, once there is evidence of plaque, I think a statin (or other risk factor modifier such as blood pressure pills) should be started.

Ask your doctor if you are on a statin for primary prevention or secondary prevention. This will help you determine whether or not you should consider continuing, or starting, a cholesterol lowering statin or not. The decision should be an individual choice, free from algorithms, so that you are comfortable with your doctor, your care, and are taking control of your health.

The question keeps getting asked: Water pills (diuretics) do not take care of my water weight problem. Why is this when aquapheresis works great?

The figure represents the water distribution of a 70 kilogram male (150 pounds) with no extra fluid. You are mostly water. If you have swelling in the legs (edema), the EXTRA fluid is located in the intersititial space. Of interest, patients with 30 pounds of edema have all that extra water weight located in the intersitial space.

According to the figure, only a tiny amount of fluid is located on the arterial side (0.7 liters or about 2 cans of Pepsi), the place where diuretics (water pills) have an effect. Too much stress placed on that system from water pills can lead to sudden kidney failure.

Since the venous compartment contains much more fluid (3.9 liters), the process of aquapheresis can pull fluid from the venous side without really affecting the arterial side -- sparing the kidneys. During aquapheresis, we take off pounds of fluid over the 3 day process because the interstitial fluid (9.4 liters or more in a patient with pitting edema in the lower extremities) replaces the removed fluid from the venous side.

We have actually seen some patient's kidney function improve during the procedure!