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Lenin 12-18-2004 06:17 AM

Monotherapy
 
My goal is monotherapy for hypertension. I've been on all the drug classes at one time or another and have settled on an ARB + HCTZ. That give me very good control, perhaps too good. (Of course in a doctor's office I still set off fire and smoke alarms when attatched to his rig.)

I am trying for either monotherapy or "natural" means to continue control. I've taken my weight down 20 pounds this year to a fine "fighting weight" and have cut drinking to near zero and have recorded an average BP of around 120/80 for many months.

I flipped a coin this weeek to see what I'll give up as a trial in my goal to monotherapy. So today is my third day without hydrochlorothiazide. BP good last night in spite of a miserable 2 pound water weight gain (2399 calories wouldn't) have done that. Yesterday 1995 calories and another 3 pounds gain. I'm noticeably edematous (and miserably) with 5 extra pounds of water even causing visible creases in my wrist. I'm SURE my BP will be high all day. I took the Cozaar very early to see if the Angiotensin blocking will help relieve SOME of the bloat.
I've gone this route before and it usually takes 5 days to blow the water off in a "brisk diuresis" (peeing all day:D) implying the body has stabilized.

Question:
Does anybody have any insight into the mechanism of this HORRIBLE rebound effect?

I'm almost tempted to switch back on the 50 mg. HCTZ and drop the ARB but I really want to see which will give me the better monotherapy for at least a two week trial of each...maybe a month would be more valid. I'm also VERY curious what kind of a rebound the ARB will have since I've been seeing references to increased renin production to compensate for Angiotensin-2 diminishment. That burst of extra renin running around with no blockade must be fun! :jester:

Palamedes 12-18-2004 06:43 AM

Re: Monotherapy
 
Lenin,

How much sodium are you eating? I would assume quite a lot since you are getting a rapid weight gain.

Another thing, if you are going to use Cozaar, you most likely need to take it twice a day. It is a very weak ARB with a short half-life. Diovan seems to be the most popular ARB. I believe Benicar is probably the most potent. Micardis has the longest half-life (24 hours). Though, I remember reading on here that some folks were having problems with 24 hour control using Micardis.

FWIW, I got absolutely zero BP control with Hyzaar (Cozaar + HCTZ) 50/12.5. However, Benicar 20 mg (no HCTZ) is giving me excellent results. My average BP before was 135/85. Now, it is averaging 116/66 on a low sodium diet. If I eat too much sodium (even for 1 day), I will put on 2-3 pounds and my BP will go up about 10/10 (losing about 1/2 the drug's potency). This will last for about 3 days after which things will settle back down.

Pal

Lenin 12-18-2004 09:51 AM

Re: Monotherapy
 
Pal,
I do about 3000 mg. sodium a day (in a 2200-2400 calorie diet) but I can't be certain...a day with cheese, canned products or Chinese food might be much more than 4 grams...a day when everything is made from scratch by me, much less than 2.

I have ALWAYS been extremely salt sensitive and get edematous easier than most people. With the several years of 50 mg HCTZ daily, the salt sensitivity went to the back burner...out of sight out of mind. It may well be that the HCTZ is all I need since my control has been excellent with 50-50 HCTZ-losartan.

I'll find out very quickly if the dose of Cozaar isn't effective as a monotherapy. I have a VERY large stockpile so another ARB is out of the question. If I find that it's the 50mg HCTZ that's been doing all my heavy lifting, then so be it- it will be diuretic monotherapy for me...but maybe a potassium sparing one. I rather like the potassium retaining (and uric acid excreting) effects of the sartan and will miss it's moderating effect on the diuretic.

Anything on the feedback loop to make one MORE salt sensitive on diuretc withdrawal...the last 2 days were lower salt but STILL 5 pounds weight gain- obviously from the lack of thiazide!
Is it yet again another renin rush (all roads seeem to go through renin, don't they?:D) Aldosterone? nor-epinephrine?...or god forbid, as far back as the pituitary?

p.s. This morning's Cozaar first thing on awakening (and weighing) seemed to bring on a healthy diuresis...notably non-saline though. I've noticed the efffect before but only when I was edematous. I can't tell the effect on the bloat, though, til tomorrow's weigh-in. (I've gotten the same diuresis with channel cblockers and beta blockers...I guess the kidney is the ultimate end of BP control...at least for me!)

p.p.s I'm going to do 1/2 hour in the sauna now!:D

Lenin 12-19-2004 08:52 AM

Re: Monotherapy
 
Well,
Systolics creeping up well over 145 though diastolics hanging beow 85. Torn between waiting to see it to fruition or adding a nighttime additional 50 mg. losartan for a total of 100 mg. for the rest of the 2 week period. I'll hang with just 50 for today. Too many changes yield bad data!

Six (6) pound water bloat still hanging on...all my joints feel it.:(

Joannofark 12-19-2004 12:17 PM

Re: Monotherapy
 
Lenin, you said you were consuming about 3000mg sodium on a 2200-2400 calorie diet. The rda is 2400mg on a 2000-2500 calorie diet--that rda is for healthy people. You may want to experiment with lowering your sodium level and see if there's any change in your bp.

Palamedes 12-20-2004 03:46 AM

Re: Monotherapy
 
[QUOTE=Joannofark]Lenin, you said you were consuming about 3000mg sodium on a 2200-2400 calorie diet. The rda is 2400mg on a 2000-2500 calorie diet--that rda is for healthy people. You may want to experiment with lowering your sodium level and see if there's any change in your bp.[/QUOTE]I agree. If you are going to consume that much sodium, you certainly are going to need a diuretic to get anywhere. The first-line treatment has to address the main problem. In this case, it's sodium consumption. In which case, the diuretic is going to be the optimal treatment. If the sodium were dropped to 1000-1500, then the ARB may be optimal for monotherapy.

Pal

Lenin 12-20-2004 05:23 AM

Re: Monotherapy
 
Well, yesterday was a 1 Gram sodium day 9WITH great EFFORT)...the 6 pound bloat is STILL hanging on.

Pal and Joan, give me an opinion:
Assume I am extremely salt-sensitive. Is it likely that taking ONLY an ARB will cause an INCREASE in my readiness to retain water by causing an INCREASE in renin-aldosterone-Angiotensin-2 as a compensation mechanism for decreasing the amount of Angiotensin-2 that can attach to vascular receptors because of the ARB blockade, and thus more sodium retention.
I DO seem more "water-retentive" on just the ONE drug than on NONE! It's beginning to look like "just Cozaar" is not an option.

Palamedes 12-20-2004 09:33 AM

Re: Monotherapy
 
[QUOTE=Lenin]Well, yesterday was a 1 Gram sodium day 9WITH great EFFORT)...the 6 pound bloat is STILL hanging on.[/QUOTE]For me, it takes about 3-4 days of low sodium and high water consumption to flush out the sodium. This is based on my experience only as I haven't been able to find any good information on this.
[QUOTE]Pal and Joan, give me an opinion:
Assume I am extremely salt-sensitive. Is it likely that taking ONLY an ARB will cause an INCREASE in my readiness to retain water by causing an INCREASE in renin-aldosterone-Angiotensin-2 as a compensation mechanism for decreasing the amount of Angiotensin-2 that can attach to vascular receptors because of the ARB blockade, and thus more sodium retention.
I DO seem more "water-retentive" on just the ONE drug than on NONE! It's beginning to look like "just Cozaar" is not an option.[/QUOTE]Yes, the ARB will make you more salt-sensitive. But, it shouldn't be causing water retention. Remember, when you block ang 2, you are also lowering the level of aldesterone produced by your adrenoline glands. And, aldesterone tells your kidneys to retain sodium. So, the ARB should actually be helping you flush out the sodium. In other words, if the ARB is working correctly, it should have mild diuretic properties all by itself.

Pal

alptraum 12-20-2004 10:27 AM

Re: Monotherapy
 
That's a lot of salt. Do you prepare any of your own meals from scratch?

Lenin 12-20-2004 01:05 PM

Re: Monotherapy
 
Sure I do, alptraum, and then the sodium is quite low.
But even if I make my own spaghetti ragu and use canned tomatoes, the sodium is astronomical. Canned beans likewise...canned ANYTHING in fact is a salt nightmare with the tiny exception of the VERY few products packaged "low sodium." Deli foods- forget it. Cheeses- forget it. Snack foods- forget it. You can make only so many roasts with 2 veg unless you want to carry a belly around in a wheelbarrow!

I think I read recently that the AVERAGE per capita salt consumption in the U.S. is 4600 mg. per day! (I think Pfizer and Merck must subsidize the canned food industry:D:D)

It iis quite difficult to keep sodium below 2000 mg. (An aside: I just read that anyone on ARB's should never restrict sodium because of the danger of Hyperkalemia.)
Damned if you do and damned if you don't.

Plan change:
Since I am not getting good control with 50 mg. Cozaar, I'm going to add 50 more at night...total 100 in divided doses. Let's see if I can stay below 140/90 on that. Less SQUISH by XXXmas would be a nice plus! I'm not optimistic but in for a penny in for a pound! (I've seemingly got aphorismitis today:D:D)

jtu91952 12-20-2004 05:02 PM

Re: Monotherapy
 
When i have to use canned veggies, i put them in a strainer and rinse them for a minute or two. Mostly i use fresh or frozen.

Lenin 12-21-2004 06:35 AM

Re: Monotherapy
 
OK,

Bloat relented some...down 4 pounds this morning in spite of a medium salt day yesterday (2 grams). The mere mention of tomato sauce and I had to have spaghetti with meatballs (and parmesan), a salty dinner...but a saltless home-made protein shake for breakfast.
It LOOKS like the thizide withdrawal caused a rrebound in sodium/water retention that lasted EXACTLY 5 days. (When I cold-turkied both drugs a couple months ago, the bloat lasted 4-5 days...so I guess I have THAT pattern pretty well established.)

Last night I raised the Cozaar to 100 mg split in half doses 12 hours apart. Fifty mg. just wasn;t cutting the mustard.
Let's see if I can get systolics under 140 consistently for a week. I've also determined that the peak BP lowering of lovastatin occurs almost precisely 2 hours after dosing!

(Splitting headache for 24 hours may or may not be significant...it started BEFORE the second 50 mg. Maybe from the diuresis? Maybe from the deep dark, cold, winter solstice. Maybe just one of those things?)

Overall, I would RATHER do a Cozaar monotherapy (if good enough) than a thiazide monotherapy because I have gout (take allopurinol) and lovastatin is uricosuric. It also RAISES potassium rather than depletes it. Thiazide do the reverse on both counts.

Palamedes 12-21-2004 09:11 AM

Re: Monotherapy
 
[QUOTE=Lenin]Sure I do, alptraum, and then the sodium is quite low.
But even if I make my own spaghetti ragu and use canned tomatoes, the sodium is astronomical. Canned beans likewise...canned ANYTHING in fact is a salt nightmare with the tiny exception of the VERY few products packaged "low sodium." Deli foods- forget it. Cheeses- forget it. Snack foods- forget it. You can make only so many roasts with 2 veg unless you want to carry a belly around in a wheelbarrow![/QUOTE]I haven't had any problems finding low sodium canned food. For spaghetti, I use no-salt added diced tomatoes and tomato paste. The sodium content is quite low. Tomato paste is usually very low in sodium and can be found anywhere. The "no salt added" stuff can be found in most grocery stores. Super Walmart is great. Even most regular Walmart's sell some of this stuff. The best low-sodium food I've found is tacos. Some brands of shells have lots of sodium, others have zero. This is usually not advertised - check the label. You do have to go easy on the cheese. I haven't found any reasonable way around this - unless you are a big fan of swiss cheese.

Pal

CASSIEBEL 12-21-2004 01:56 PM

Re: Monotherapy
 
Very interesting info, Lenin. You too Pal. I take Benicar HCT with good results. Previously, Micardis HCT ( not good control at all ). With the Micardis taken AM BP would go down to normal but about 6 hours later would be up (high up) With Benicar I get consistant readings.

I am interested in the way ARB's and diuretics affect potassium. I took HCT previously with a CCB and had to stop due to very low potassium. My cardiologist assured me that would not happen with the ARB.
We shall see.

It's good to be back. Been computer-less for awhile :bouncing:

Cassiebel

Lenin 12-22-2004 05:56 AM

Re: Monotherapy
 
Well, I figured out the reason for the two days of headaches...it's a full blown head cold now (with some chills overnight.) No joint pains YET but I'm worried about the flu I'll take temperature after morning coffee is well and truly gone..
Yesterday's numbers with the 100 mg dual dosing were much the same as the losartan 50 mg. single dose (about 140-150/88-94) but I guess with a frontal virus attack in process, I shouldn't be too quick to judge on the basis of one day's reading. I'll give it a week or two.
(I really am beginning to suspect the necessary rationale behind the development of HYZAAR.)


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