Blog posts of '2016' 'November'


Hypertension in Pediatrics

- Saturday, November 26, 2016
Hypertension in children depends on age, gender and height specific blood pressure percentiles that can be calculated using the calculators below:
*Calculators for boys ( calculator 1 ) or for girls ( calculator 2 ).
o   Normal blood pressure is defined as both systolic and diastolic blood pressure <90 th percentile.
  • Prehypertension – Systolic and/or diastolic BP ≥90 th percentile but <95 th percentile or if BP exceeds 120/80 mmHg
  • Hypertension (HYPERTENSION) – HYPERTENSION is defined as either systolic and/or diastolic BP ≥95 th percentile measured upon three or more separate occasions.
  • Stage 1 hypertension – Systolic and/or diastolic BP between the 95 th percentile and 5 mmHg above the 99 th percentile.
  • Stage 2 hypertension – Systolic and/or diastolic BP ≥99 th percentile plus 5 mmHg.

Hypertension in children, can also be divided into:

  • Primary: no identified cause of hypertension.
  • Secondary: hypertension is due to a certain cause.
Treatment of hypertension in pediatrics should be initiated with pharmacological/ non pharmacological and in cases of secondary hypertension the cause should be identified and treated to prevent the development of early cardiovascular disease.

Non-pharmacological measures:

These measures should be done for children with hypertension and pre-hypertension: 
o   1. Weight reduction in obese patients (especially in children with type 2 diabetes)
o   2. Regular exercise (20 to 60 minutes of aerobic exercise three to four times a week) and limitation of sedentary activities to less than two hours per day.
o   3. DASH diet (low salt diet and increase fresh fruits and vegetables and low fat diary products)
·       It is advised that Sodium intake is restricted to 2 g/day, which corresponds to a salt intake of 3.1 g/day
·       Avoid food high in salt like potato chips and canned, processed food
o   4. Avoid smoking
o   5. Frequent blood pressure monitoring 

Pharmacological therapy

When to treat?
  • Symptomatic patients (headache, seizures, changes in mental status, focal neurologic complaints, visual disturbances, and cardiovascular complaints indicative of heart failure, such as chest pain, palpitations, cough, or shortness of breath).
  • Stage 2 HYPERTENSION defined above.
  • Stage 1 hypertension that persists despite a trial of four to six months of non-pharmacologic therapy.
  • Hypertensive target-organ damage, most often left ventricular hypertrophy (LVH).
  • Stage 1 hypertension in patients with diabetes mellitus or dyslipidemia
  • Prehypertension in presence of comorbid conditions, such as chronic kidney disease or diabetes mellitus.
Pharmacotherapy should be initiated with the goal to prevent premature cardiovascular disease and lower blood pressure to target goals.

Blood pressure goals:

  • In children and adolescents with hypertension and no evidence of target-organ damage, comorbid risk factors, or cardiovascular disease; the targeted goal is less than the 95 th percentile based upon age, height, and gender.
  • If there are comorbid risk factors (eg, obesity or dyslipidemia), cardiovascular diseases (eg, diabetes mellitus), or chronic kidney disease, the BP targeted goal is lowered to below the 90 th percentile for age, height, and gender.
Antihypertensive drugs:
Thiazide diuretics  
thiazide diuretics can be considered an effective and safe option in children, can be given alone or in combination.
Start with 1mg/ kg/ day to a maximum of 3 mg/kg/ day or 50 mg
Close monitoring of blood chemistry is required
Start with 0.5 mg/kg/day to a maximum of 2mg/kg/ day or 50 mg
Avoid in patients with renal impairment as it may cause azotemia
ACE inhibitors/ARBs  
Ace inhibitors & ARBs are approved for children older than 6 years, and are the preferred choice for children with diabetes mellitus  and chronic kidney disease due to renal protective effects.
Black children appear to require higher doses of Ace inhibitors than non-black children.
All Ace inhibitors/ ARBs should be avoided in females of childbearing age, unless a reliable contraception method is used.
Start with 0.08 mg/kg per day up to 5 mg/day and titrate to 0.6 mg/kg per day up to 40 mg/day
Monitor potassium levels and renal function
0.07 mg/kg per d up to 5 mg/day and titrate to 0.6 mg/kg per day up to 40 mg/day
Monitor potassium levels and renal function
0 .2 mg/kg per day up to 10 mg/day
and titrate to 0.6 mg/kg per day up to 40 mg/day
Monitor potassium levels and renal function
5-10 mg/ day and up to 40 mg daily
Used in children > 50 kg only.
Monitor potassium levels and renal function
0.7 mg/kg per day up to 50 mg/day
and up to 1.4 mg/kg per day
Monitor potassium levels and renal function
Beta blockers  
 Beta blockers are one of the first options for children with hypertension.
1-2 mg/kg/ day and to a maximum of 4 mg/kg/day
Contraindicated in children with asthma, heart block.
Avoid in insulin dependent diabetics
1-2 mg/kg/ day and to a maximum of 6mg/kg/day
Avoid in insulin dependent diabetics
0.5-2 mg/kg/day
Avoid in insulin dependent diabetics
Start with 1-2mg/ kg/day and up to 10-12 mg/kg/day
Contraindicated in children with asthma, heart block.
Avoid in insulin dependent diabetics
Calcium channel blockers  
Considered the drug of choice in cases of asthma and hypertension, also preferred in cases of secondary because it will not affect renal function.
2.5-5 mg daily
For children 6 years and older.
Check heart rate
2.5 mg-10 mg daily
Check heart rate
Nifedpine (extended release)
Start with 0.25 -0.5 mg/kg/day and up to 3 mg/kg/day
Check heart rate
Tablets must be swallowed whole
Continued follow-up is required to monitor the response to therapy and to detect any drug-related adverse effect.
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An Overview of Hypertension Treatment

- Wednesday, November 23, 2016

Hypertension is the one of the most common cardiovascular conditions that must be treated aggressively to prevent any complication, including myocardial infarction, stroke, renal failure, and death.


According to the JNC 8 guidelines, hypertensive patients over 60 years old must be treated with a blood pressure goal of less than 150/ 90 mm HG, while younger hypertensive patients (less than 60 years) should be treated with a goal of less than 140/90 mm Hg including diabetic patients and patients with chronic kidney disease.


Initial treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). Except for black population, treatment should include a thiazide-type diuretic or CCB.


The JNC 8 did not recommend β-blockers for the initial treatment of hypertension because it resulted in a higher rate of cardiovascular death, myocardial infarction, or stroke compared to use of an ARB.

Also they don’t recommend using α-Blockers as first-line therapy because in one study initial treatment with an α-blocker resulted in worse cerebrovascular, heart failure, and combined cardiovascular outcomes than initial treatment with a diuretic.


According to studies Initial treatment with a thiazide-type diuretic was more effective than a CCB or ACEI for preventing heart failure, and an ACEI was more effective than a CCB in improving heart failure outcomes.


For patients with chronic kidney disease (regardless of race), treatment should include an ACEI or ARB as these agents improve kidney function.


Agents approved by JNC8 for hypertension treatment:


Initial dose in mg

Target dose in mg



150-200 in 2 doses



20 in 1-2 doses



40 in 1 dose



600-800 in 1-2 doses



12-32 in 1 dose



100 in 1-2 doses



160-320 in 1 dose



300 in 1 dose



10 in 1dose

Diltiazem extended release


360 in 1 dose



20 in 1-2 dose




100 in 1 dose



12.5 -25 in 1 dose



25-100 in 1-2 dose



1.25-2.5 in 1 dose


Our goal is to maintain blood pressure goals according to age; ensuring patient adherence to treatment and to lifestyle measure ( low sodium diet, weight control, avoid smoking and exercise) is important to achieve your goal. if goal can be achieved with one agent we can increase the dose to the maximum and then add another agent from another class (thiazide-type diuretic, CCB, ACEI, or ARB). If goal is still not reached with 2 drugs with maximum doses we can add a third agent. Do not use an ACEI and an ARB together in the same patient. If blood pressure goal is still not achieved after using 3 agents, antihypertensive drugs from other classes can be used (eg, β-blocker, aldosterone antagonist, or others)



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Treatment of osteoporosis in males

- Saturday, November 19, 2016


The treatment of osteoporosis in men consists of lifestyle measures and drug or hormonal therapy.

Non pharmacological therapy

1.   Weight-bearing exercise.

2.   Calcium and vitamin D supplementation:

1000 -1200 mg of calcium daily and 600-800 units of vitamin D

Secondary osteoporosis:

 The cause of secondary osteoporosis should be identified and treated.

For example Testosterone therapy  can be used to increase bone mineral density in young men with hypogonadism

Pharmacological therapy:

We start with fracture risk assessment using FRAX score calculator which estimates the 10-year probability of hip fracture or major osteoporotic fractures combined (hip, spine, shoulder, or wrist) for an untreated patient using femoral neck BMD and other risk factors for fractures:


When to start pharmacotherapy?

1.   Men ≥50 years with a history of hip or vertebral fracture or with osteoporosis (T-score ≤-2.5).

2.    Men with osteopenia (T-score between -1.0 and -2.5) and with a10-year probability of hip fracture reaches 3 percent or the 10-year probability of osteoporotic fractures combined is ≥20 percent.

3.   For those at moderate risk (10 to 20 percent), the decision to treat should be based upon the presence of additional risk factors.

Choice of therapy  

Bisphosphonates are considered the treatment of choice.

Patients can start with weekly alendronate and risedronate, when oral bisphosphonate is intolerable patients can use IV zoledronic acid.

When zoledronic acid is intolerable or for patients with renal impairment (bisphosphonates are not recommended when GFR<30 ml/min), denosumab is the drug of choice.

 Another option is Teriparatide, which can be used for men with severe osteoporosis (T score <-2.5) and at least one fragility fracture), or men who have failed previous therapy.

Denosumab prevents bone loss and reduces vertebral fracture risk in men with nonmetastatic prostate cancer receiving androgen deprivation therapy. Also, used in males with impaired renal function.

  In case of treatment failure and no availability of another option, strontium ranlate can be used which acts by inhibiting bone resorption and may increases bone mineral density.

In males whit growth hormone deficiency, Growth hormone growth factor can be used


1.   Patient adherence to therapy

2.    BMD measurements, obtain a follow-up DXA of hip and spine after two years, and if BMD is stable or improved, less frequent monitoring is needed.


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- Saturday, November 19, 2016


Osteoporosis is a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes, or deficiency of calcium or vitamin D.





Some life style changes can be done to prevent osteoporosis, including the following:

1.maintain an adequate calcium and vitamin D levels is the first step in preventing osteoporosis.

Post-menopausal females should have a calcium intake of 1200 mg/ day as a total level from both food and calcium supplements. Calcium supplements can be taken as 500-1000 mg daily with meals. Vitamin D supplements may be needed to maintain D3 blood level of 30-60 ng/ml.

2. Limit alcohol intake to less than 2 servings daily

3. Limit caffeine intake

4. Moderate exercise 30 minutes daily

5. Avoid smoking




Who should screen for osteoporosis?

1.     Female 65 years and older.

2.     Younger postmenopausal women with fractures risk factors (Prior low-trauma fracture as an adult, Advanced age, Low bone mineral density Low body weight or low body mass index, Family history of osteoporosis, Use of corticosteroids Cigarette smoking Excessive alcohol consumption Secondary osteoporosis)




Osteoporosis is diagnosed using a central dual-energy x-ray absorptiometry (DXA) measurement.

In the absence of fracture, osteoporosis is defined as a T-score of -2.5 or below in the spine, femoral neck, or total hip.

Osteoporosis is defined as the presence of a fracture of the hip or spine.


Pharmacological treatment:

Once patient is diagnosed with osteoporosis (history of a hip or spine fracture, No fractures but with a T-score of -2.5 or lower, Patients with a T-score between -1.0 and -2.5 if FRAX major osteoporotic fracture probability is ≥20% or hip fracture probability is ≥3%)



 Bisphosphonates are first-line therapy for postmenopausal osteoporosis. We prefer oral bisphosphonates as initial therapy because of their efficacy,long term safety data and low cost.

In cases of intolerance to gastrointestinal side effects, we can use IV zaledronic acid, which has been demonstrated to reduce vertebral and hip fractures.

also, denosumab can be used as initial therapy in certain patients at high risk for fracture, such as older patients who have difficulty with the dosing requirements of oral bisphosphonates, patients unresponsive to other therapies and in those with impaired renal function.

Strontium ranelate can be used by women who cannot tolerate or are unable to take oral or intravenous bisphosphonates.

raloxifen is used for patients who cannot tolerate any bisphosphonates or for women with osteoporosis and increased risk of invasive breast cancer.


Other therapies:


 Tibolone, a synthetic steroid whose metabolites have estrogenic, androgenic, and progestagenic properties and can be used for osteoporosis management.

Growth factors:

Only effective in patients with growth hormone deficiency.



Health care practioners should monitor the patient for the following:

1.     Adherence to therapy

2.      Calcium and vitamin D levels

3.     DXA of hip and spine after two years, and continous monitoring according to response

4.    Biochemical markers including fasting urinary N-telopeptide (NTX) or serum carboxy-terminal collagen crosslinks (CTX) 

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smoking cessation

- Friday, November 18, 2016


Cigarette smoking is the leading preventable cause of mortality. Smokers who stop smoking reduce their risk of developing and dying from tobacco-related diseases. To increase smoking cessation rates, patient’s smoking status should as assessed and documented in every visit

Behavioral counseling and pharmacotherapy produces the best results when combined together.  

Smoking status assessment:

Practioners should first assess the patient's tobacco use; including the duration of smoking history, the number of cigarettes smoked daily, and how soon after waking up the smoker has his first morning cigarette. More dependent smokers have smoked for many years, smoke more cigarettes daily, and smoke within the first 30 minutes of awakening.

The desire to stop smoking, and the history of previous quit attempts, the smoker's degree of nicotine dependence predicts the difficulty in quitting and the intensity of treatment needed.


Quitting barriers:

Smokers face several difficulties when they try to quit. The addictiveness of nicotine is the primary barrier.

Nicotine withdrawal syndrome:

In the absence of nicotine, a smoker develops cravings for cigarettes and symptoms of the nicotine withdrawal syndrome. These symptoms include:

  • depressed mood
  • Insomnia
  • Irritability, frustration, or anger
  • Anxiety
  • Difficulty concentrating
  • Restlessness
  • Increased appetite or weight gain

These symptoms should be will known by practioners and patients so patients can know what to expect and how to deal with these symptoms.

Other barriers include daily activities associated with smoking like morning coffee, an alcoholic drink, or the end of a meal. These triggers contribute to the difficulty smokers have in smoking cessation.

Smoking cessation treatments:  

Behavioral counseling  

Behavioral counseling includes direct patient-clinician encounters, via telephone, computer programs, text messaging, or group-based therapy. The most intensive behavioral intervention acceptable to the patient should be offered. A simple five-step algorithm called the 5 A's (Ask, Advise, Assess, Assist, Arrange) helps you in remember counseling elements:




Smoking status should be assessed for every patient and documented in his medical files


Strongly advice all smokers to quit in a clear, strong, personalized manner.



assess the patient’s willingness to quit in the next 30 days.

If the patient is willing to quit smoking provide assistance, while if the patient is not willing to quit smoking a motivational intervention is needed



Provide assistance to patients trying to quit smoking by behavioral counseling and pharmacotherapy


Arrange for a follow up appointment, preferably in a week


Most former smokers had to try to quit several times before they finally achieved success so the clinician should assess the smoker's previous experiences with attempts to quit. Assessing the methods that have been tried and the smoker's degree of success with each in order to guide recommendations for the next attempt.

The first step in Setting a quit plan is setting a quit date preferably within the next two weeks. Patients should be directed to stop smoking completely on their quit day and should be familiar with nicotine withdrawal symptoms and how to deal with it.

Some patients begin to reduce smoking in the days and weeks prior to the quit date. Also removing tobacco products from the environment and asking family and friends for support will increase smoking cessation rates.

Follow-up  — A follow-up visit should be scheduled within three to seven days of the patient's quit day to monitor response to smoking cessation therapy. Then patients should then be followed monthly for at least three months.  

Difficulty quitting and relapse 

When patients fail to stop smoking after the quit date, practioners should identify the cause of failure. Different reasons could contribute to this including high nicotine dependent, low self-confidence or little social support for quitting, not using medications optimally (eg, chewing nicotine gum too rapidly, failure of the medication to reduce nicotine withdrawal, or intolerance of medication side effects).

In this case you should remind your patients that they might need multiple attempts before they quit smoking permanently.

Always remember to ensure patient adherence and to intensify behavioral counseling.

Relapse prevention  

 Long-term follow-up is very important because even successful quitters can remain at high risk of relapse for several years after smoking cessation.

The clinician should encourage and congratulate the patient on quitting; simply asking how their lives have changed since they stopped smoking can highlight the benefits of smoking cessation. Also, it is important to know if the patient is facing any problems due to smoking cessation (eg, weight gain, depression, alcohol use) and to help him accordingly.

Management of relapse:

Lack of support for cessation


Schedule follow up visits, refer the patient to an appropriate cessation counseling organization

Negative mood or depression


Provide counseling, prescribe appropriate medications, or refer the patient to a specialist


Strong withdrawal symptoms

Consider adding/ combing pharmacotherapy

Weight gain

Ensure the importance of a healthy diet and physical exercise

Reassure the patient that some weight gain after quitting is common and appears to be self-limiting


Flagging motivation

Reassure the patient that these feelings are common

Recommend rewarding activities



Smoker who are not ready to quit yet!

 For smokers who are not ready to quit, you have to assess the patient's motivation, benefits and risks in order to help the smoker to begin to think about quitting. A personalized message concerning a smoking-related health problem of the smoker himself or a family member may motivate some patients to quit smoking


Pharmacologic treatments:

First-line drug therapy for smokers includes

1.     Nicotine replacement therapy incuding nicotine gum, lozenges, spray and patches

2.     Buprobion

3.     Varenicline (champix)


Behavioral counseling in addition to pharmacological treatment when combined is better than either alone in increasing smoking cessation rates. The choice of pharmacological agent depends on patient preference, previous experience with the drugs, cost and medical conditions.

Light smokers: 

Behavioral counseling is the first line treatment for those who smoke 10 cigarettes per day or less.

Pharmacotherapy can also be used in light smokers who do not respond to behavioral counseling. The doses of nicotine replacement therapy, bupropion , and varenicline should be reduced for use in this population.


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osteoporosis in males

- Friday, November 18, 2016



Osteoporosis is characterized by bone fragility and low bone mass, resulting in an increased risk of fracture especially in the hip, wrist, humerus, rib, and pelvis.

Early diagnosis of osteoporosis is important to make the progression of the disease slower. Diagnosis of osteoporosis is based on bone mineral density (BMD) measurement by DXA of hips or spine bones. BMD testing is recommended for all males older than 70 years and in men 50 to 70 years when risk factors as radiographic osteopenia, history of low trauma fractures , and loss of more than 1.5 inches in height, long-term glucocorticoid therapy, androgen deprivation therapy for prostate cancer, hypogonadism, primary hyperparathyroidism, and intestinal disorders.


T-score of DXA

Normal bone mineral density

T-score greater than or equal to -1 SD


T-score less than -1 and greater than -2.5 SD


T-score less than or equal to -2.5

Severe osteoporosis

T-score less than or equal to -2.5 with one or more fragility fractures.



Osteoporosis usually has no symptoms until there is a fracture. symptomatic vertebral fractures include pain and height loss.

Sometimes symptoms may be accompanied with other causing diseases hypogonadism, malabsorption, vitamin D deficiency, diabetes,  and hyperparathyroidism.

Secondary osteoporosis:

always check if there a secondary cause of osteoporosis before initiating any pharmacotherapy, such as renal or liver disease, hyperparathyroidism, Cushing's syndrome, celiac disease and other forms of malabsorption, or idiopathic hypercalciuria or if patient is using any medication that decrease bone mineral density, such as (heparin, glucocorticoids, anti convulsant, chemotherapy, cyclosporine). 


Glucocorticoid-induced osteoporosis:


the increased risk of fracture has been reported with doses of prednisolone or its equivalent as low as 2.5 to 7.5 mg daily.

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