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My age is 40 and I have been suffering from Ankylosing Spondylitis (HLA B27 Positive) for the last 17 years. I take Methotrexate 7.5 mg , 1 tablet once a week and Sulphasalazine 1000 mg 1 tablet daily before lunch. Also I take HCQS and Lefra 10, 1 tablet each everday after lunch. I have a chronic problem of Hypertension (BP of 203/113) although I never feel any bodily discomfort from such very high BP levels. I underwent some diagnostic tests recently: 1) Echocardiography, 2) USG of Kidney and Urinary Bladder, 3) Color Doppler study of Renal Artery, and 4) Lipid Profile, Fasting Sugar and Creatinine. I will upload these reports for your convenience and would like to get advised on future medication/treatment for this Hypertension and its resultant damages (if any). Thank you.

Category: Cardiologist

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Category: Cardiologist
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Thank you for your query at
You have uncontrolled hypertension. May I know the drugs that you are taking for hypertension?
Methotrexate is known to cause severe hypertension in patients taking the drug. Le?unomide-related hypertension has been noted in up to 10% of patients. Even sulfasalazine is known to precipitate hypertension in users.
The investigations so far have revealed that you don't have renal artery stenosis as a cause of hypertension. Other causes need to be ruled out.
You should have serum and urine electrolyte testing done. Additionally urine and serum catecholamines and dexamethasone suppression test shoild be done to rule out other secondary causes of hypertension. The blood pressure is damaging your kidneys by causing albuminuria. The heart is getting affected in the form of left ventricular hypertrophy (that is the heart muscle of your left ventricle has thickened in response to the elevated blood pressure). Therefore it is of the utmost importance that your Blood pressure needs to be aggressively controlled
Kindly provide details of antihypertensive drugs

Patient replied :

I am taking Thalitel 40 (Telmisartan & Chlorthalidone) 1 tablet at 9 am and Metocard AM (Metoprolol Succinate Extended Release & Amlodipine Besilate) 1 tablet at 9 pm and Modlip-20 (Atorvastatin Calcium) 1 tablet after dinner everyday for the last 5 days. Before that I have never taken any antihypertensive medication in my life. Please advise on what tests do I need to get done next and is it required to remove the kidney stones (as mentioned in the USG of KUB and Doppler of Renal Artery). Can kidney stones be a cause of very high BP? I do not experience any pain or discomfort due to bilateral nephrolithiasis. Please advise on my future course of action. Thank you.

If your renal function is unimpaired which means that if your creatinine levels are normal then the kidney stones are not a cause of your elevated blood pressure. For your kidney stone removal surgery your blood pressure should be less than 170/100 and preferably leas than 150/90. If you can walk 2 floors and half a kmat a brisk pace then you can undergo kidney stone remkval surgery. You should continue the antihypertensive medicines in the peri operative period and do not stop it.

Dr Vivek Mahajan

Patient replied :

Hello Doctor
My Serum Creatinine level is 1.15 mg/dL (as on Oct. 31, 2014). Please specify what additional blood tests over and above those I have already got done (and their reports submitted to you) should I undergo to rule out probable causes of hypertension. Please specify the names of those tests so that I can directly order those tests at the diagnostic lab. Also, should I be taking the antihypertensive drugs that I gave the details of, the day before I get my blood sample collected ? Please advise. Thank you.

Thank you for your follow up.
Apart from the ones you have sent, which essentially rules out Renal Artey stenosis, i will advise :
1) Serum Electrolytes.
2) Dexamethasone Suppression Test
3) Urine spot albumin creatinine ratio.
4) Lipid profile
5) For surgical purposes you will need recent ECG and 2D ECHO.
Yes please do continue the antihypertensive drugs. And get back to me with the reports of the above mentioned tests.

Patient replied :

Hello Doctor
Apologies on behalf of the path. lab. for misprinting your surname. Except for Dexamethasone Suppression Test and that numbered 5 in your advised list, the rest of them have been done.DSTest was not available at the path. lab. I've uploaded for you Serum Electrolytes, FBS and Urine spot albumin-creatinine ratio test failed to upload after I uploaded the Serum Electrolytes, FBS tests perhaps because it consumed 0.4MB space.However I'll quote figures from the Urine test here:
Urinary Albumin: 9600 mcg/dl
Urinary Creatinine: 54.6 mg/dl
Ratio [Albumin:Creatinine]: 175.8 mcg/mg
[Interpretation of the ratio:
<30 mcg/mg: Normal
30 - 300 mcg/mg: Microalbuminuria
>300 mcg/mg: Macroalbuminuria/Advanced Nephropathy]
And as far as the Lipid Profile test is concerned, I have already uploaded the same earlier and it can found under 'Dr Lal PathLabs...' above...I'd request you to kindly go through the Lipid Profile Test results uploaded above. Please advise, based on the reports, as to what medication should I take and for how long should it be taken. Also, please advise me on the diet I should take - what foods to avoid partially/completely and what food to not avoid at all. Do you think I should see a Urologist. Please advise on how to bring down my BP to acceptable and safe levels. I take Anavite (Gaspari Nutrition), 3 tablets or Opti Men (Optimum Nutrition) 3 tablets every morning after breakfast. Can this contribute in any way towards such high BP levels ? Should I discontinue taking Anavite/Opti Men ? Please advise. Thank you Doctor.

Thank you for the follow up.
Apart from microalbuminuria, and bilateral nephrolithiasis there is no other significant abnormality in your reports. Your lipid profile is also borderline.
In this scenario it would be prudent to continue Thalitel 40 and Metocard AM, for a month and then get your BP rechecked.
If it is normal, then we can moderate the dosage. But you need to continue the medicines not even skipping one single dose.
Regarding the supplements it is unlikely to cause any harm, but not a lot of data is available. So i can't say for sure. Better to avoid if possible.
Regarding diet, avoid fatty/oily foods, restrict salt in your diet, and make sure you walk daily for 30-45 minutes.
You can get back to me after a month with your BP levels and i will guide you further.

Dr. Vivek Mahajan
Category: Cardiologist
Fellowship: DM, Cardiology, PGIMER, 2013
Residency: MD, Internal Medicine, AIIMS, 2007
Internship: King Edward Memorial (KEM) Hospital, 2003 
Medical School: MBBS, Seth G.S. Medical College, 2002
Dr. Vivek Mahajan and 4 other Medical Specialists are ready to help you

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