Canagliflozin (Invokana) is a selective sodium glucose cotransporter-2 (SGLT-2) inhibitor that was first introduced in 2013 for the treatment of type 2 diabetes mellitus (DM). Though not FDA approved yet, its use in type 1 DM has been justified by the fact that its mechanism of action is independent of insulin secretion or action. However, some serious side effects, including severe anion gap metabolic acidosis and euglycemic diabetic ketoacidosis (DKA), have been reported. Prompt identification of the causal association and initiation of appropriate therapy should be instituted for this life threatening condition.
Masked hypertension (MH), the presence of normal office blood pressure (BP) with elevated ambulatory pressure, has been shown to correlate with organ damage. Population‐based studies from Europe and Asia estimate a prevalence of 8.5% to 15.8%. Two small studies in African Americans estimate a prevalence >40%. Therefore, the authors utilized ambulatory BP monitoring (ABPM) to identify the prevalence of MH in our African American population. Pressure was recorded every 30 minutes while awake and every 60 minutes while asleep. Patients with 24‐hour average BP ≥135/85 mm Hg, awake average BP ≥140/90 mm Hg, or asleep average BP ≥125/75 mm Hg had MH. Seventy‐three participates had valid data. The mean age of the patients was 49.8 years, mean body mass index was 31.1, and 39 patients (53%) were women. Thirty‐three patients (45.2%) had MH. Patients with MH had higher clinic systolic BP and trended toward higher BMI values. The authors corroborated the high prevalence of MH in African Americans. ABPM is critical to diagnose hypertension in African Americans, particularly in those with high‐normal clinic pressure and obesity.
Cardiac sarcoidosis is one of the uncommon causes of heart failure. Generally, it presents in the form of varying clinical manifestations ranging from asymptomatic to fatal arrhythmias such as ventricular tachycardia and complete heart block. It is difficult to make a diagnosis strictly based on clinical grounds. However, in the setting of extracardiac sarcoidosis and patients presenting with advanced heart block or ventricular arrhythmia, direct cardiac involvement should be suspected. The definitive diagnosis of cardiac sarcoidosis can be made from endomyocardial biopsy, but it is falling out of favor due to patchy myocardial involvement, considerable procedure-related risks, and advancement in additional imaging modalities. Once cardiac sarcoidosis has been diagnosed, management of the disease remains challenging. Steroids are considered the mainstay of therapy, and implantable cardioverter defibrillator therapy can be considered in a selected group of patients at greater risk for malignant ventricular arrhythmias.
Patient: Male, 53Final Diagnosis: Acute Warfarin toxicitySymptoms: —Medication: WarfarinClinical Procedure: —Specialty: HematologyObjective:Unusual clinical courseBackground:Warfarin remains the most common anticoagulant in the management of thromboembolic diseases. However, its extensive drug interaction requires frequent monitoring and dose adjustments. Almost all antibiotics, including penicillins, have the potential to interact with warfarin causing either under or over anticoagulation which increases the risk for thrombus formation and significant bleeding respectively.Case Report: A 53-year-old Caucasian male with a history of protein C deficiency and recurrent intravascular thrombosis developed a dental abscess. He was treated with amoxicillin/clavulanate 500/125 mg twice daily and referred to a dentist. He developed significant bleeding after tooth extraction. INR was 20.4. He received fresh frozen plasma and vitamin K with resolution of bleeding.Conclusions:While rare, clinically significant prolonged prothrombin time and potentially life threatening bleeding can occur when amoxicillin/clavulanate is concomitantly administered with warfarin. Prompt recognition and intervention is necessary to avoid life threatening complications from warfarin-amoxicillin/clavulanate interaction.
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