What is the next step in managing a 92-year-old patient with Congestive Heart Failure (CHF) on Kerendia (finerenone), Bumex (bumetanide), finasteride, and Vyndamax (tafamidis) who presents with cold intolerance and hypersomnolence with a normal Thyroid-Stimulating Hormone (TSH) level?

Evaluation and Management of Cold Intolerance and Hypersomnolence in a 92-Year-Old with CHF

Thyroid function testing beyond TSH should be performed to evaluate for central hypothyroidism, which is the most likely cause of this patient's symptoms despite normal TSH.

Clinical Assessment

The 92-year-old patient with congestive heart failure (CHF) presents with two concerning symptoms - cold intolerance and hypersomnolence - while on a complex medication regimen including:

• Kerendia (finerenone) - mineralocorticoid receptor antagonist
• Bumex (bumetanide) - loop diuretic
• Finasteride - 5-alpha reductase inhibitor
• Vyndamax (tafamidis) - transthyretin stabilizer

While the normal TSH initially appears reassuring, this combination of symptoms strongly suggests the possibility of central hypothyroidism or medication-related adverse effects.

Diagnostic Approach

Step 1: Complete Thyroid Function Testing

• Despite normal TSH, measure free T4 (and possibly free T3) to evaluate for central hypothyroidism
• Central hypothyroidism presents with normal TSH but low free T4 levels and can cause both cold intolerance and hypersomnolence

Step 2: Medication Review for Potential Contributors

1. Polypharmacy assessment is critical in elderly patients with multiple medications 1

   • Review for drug-drug interactions, especially with multiple cardiovascular medications
   • Assess for medication side effects that could contribute to symptoms

2. Specific medication considerations:

   • Finerenone (Kerendia): Can cause initial decline in renal function 2
   • Bumetanide (Bumex): May contribute to electrolyte abnormalities 3
   • Multiple cardiovascular medications: Potential for hypotension contributing to fatigue

Management Algorithm

If Central Hypothyroidism Confirmed (Low Free T4 with Normal TSH):

1. Initiate thyroid hormone replacement therapy
2. Start with low-dose levothyroxine (25-50 mcg daily) given patient's advanced age and CHF
3. Monitor for cardiac effects during initiation
4. Recheck thyroid function in 6-8 weeks

If Medication-Related Effects Suspected:

1. Consider deprescribing approach 1:

   • Evaluate each medication for continued benefit vs. risk
   • Simplify regimen when possible to reduce pill burden
   • Adjust timing of medications to minimize interactions

2. Specific medication adjustments:

   • Consider reducing bumetanide dose if overdiuresis is contributing to symptoms
   • Evaluate need for finasteride in a 92-year-old (risk vs. benefit)
   • Monitor for electrolyte abnormalities, especially hyponatremia which can cause fatigue

If Both Approaches Fail:

1. Consider referral to sleep medicine for evaluation of hypersomnolence
2. Evaluate for other causes of cold intolerance (anemia, malnutrition, etc.)

Important Considerations

Avoid These Medications:

• Do not add sedating medications which could worsen hypersomnolence
• Avoid calcium channel blockers which are not recommended in HFrEF 1
• Avoid NSAIDs which can worsen heart failure 1

Monitor For:

• Signs of worsening heart failure
• Electrolyte abnormalities (especially potassium with finerenone)
• Renal function changes
• Orthostatic hypotension

Special Considerations in Elderly Patients with CHF

1. Medication burden: Elderly patients are particularly vulnerable to adverse effects of polypharmacy 1

2. Heart failure management: Maintain guideline-directed medical therapy while addressing symptoms 1

3. Age-appropriate care: Consider quality of life and symptom management as primary goals in a 92-year-old patient

4. Thyroid disorders: Central hypothyroidism is often missed when only TSH is measured, and thyroid hormone replacement may be needed even with normal TSH 1