What is the best course of treatment for a patient with hypertension, seborrhoeic dermatitis, gout, hyponatraemia, asymptomatic pre-diabetes, and slightly raised TSH levels?

Management of Hypertension, Seborrhoeic Dermatitis, Gout, and Hyponatraemia

Continue the current triple antihypertensive therapy with close monitoring of sodium levels, discontinue allopurinol given the absence of confirmed gout attacks, continue ketoconazole for seborrhoeic dermatitis, and address the chlorthalidone-induced hyponatraemia through dose reduction or switching to a different diuretic if sodium continues to decline. 1

Hypertension Management

Current Status and Target

• Blood pressure control has improved on triple therapy (RAS blocker + CCB + chlorthalidone), which aligns with guideline-recommended combinations 1
• For patients with pre-diabetes (HbA1c elevated), the target systolic BP should be 130 mmHg and <130 mmHg if tolerated, but not <120 mmHg 1
• The current triple-drug regimen represents appropriate escalation for uncontrolled hypertension 1

Medication Strategy

• Continue the triple therapy as this combination (RAS blocker + dihydropyridine CCB + thiazide-like diuretic) is the recommended first-line approach for patients requiring three drugs 1
• Single-pill combination formulations are preferred when available to improve adherence 1
• If BP remains uncontrolled despite maximally tolerated triple therapy, adding low-dose spironolactone should be considered next 1

Hyponatraemia Management

Addressing Diuretic-Related Sodium Depletion

• The mild hyponatraemia (sodium declining from previous values) is likely chlorthalidone-related, as thiazide-like diuretics commonly cause this adverse effect 1
• Monitor sodium levels every 2-4 weeks until stable, along with kidney function and potassium 1
• Consider reducing chlorthalidone dose if sodium continues to decline or falls below 130 mmol/L 1
• If hyponatraemia worsens or becomes symptomatic, switch from chlorthalidone to a different diuretic (such as indapamide at lower equivalent dose) or substitute with an alternative third agent 1

Critical Monitoring Parameters

• Check eGFR, sodium, and potassium before any medication adjustments 1
• The current eGFR indicates adequate renal function for continued thiazide-like diuretic use, but requires ongoing surveillance 1

Gout Prophylaxis Review

Discontinuation Recommendation

• Discontinue allopurinol given the questionable indication—no clear documented gout attacks, only bilateral knee pain with features more consistent with osteoarthritis 2
• The nocturnal knee pain and difficulty rising from chairs with joint line tenderness suggests degenerative joint disease rather than gout 2
• Allopurinol prophylaxis is only indicated for patients with recurrent gout attacks (typically ≥2 per year), chronic gouty arthritis, or tophi 2

Alternative Management

• If acute gout is suspected in the future, colchicine 0.6 mg once, followed by 0.3 mg one hour later can be used for acute flares, with dose adjustment for renal function (current eGFR requires monitoring but not dose reduction) 2
• Consider uric acid level measurement if there is clinical uncertainty, though treatment decisions should be based on clinical gout attacks, not asymptomatic hyperuricemia 2

Seborrhoeic Dermatitis Management

Current Treatment

• Continue ketoconazole cream 2% twice daily as prescribed, with the standard treatment duration being four weeks for seborrhoeic dermatitis 3
• The condition is reportedly resolving, which is appropriate progress 3
• If no clinical improvement after four weeks, reassess the diagnosis 3

Metabolic Considerations

• Seborrhoeic dermatitis has been associated with metabolic syndrome parameters including hypertension and dyslipidemia 4
• This patient's pre-diabetes and hypertension support screening for full metabolic syndrome components (waist circumference, lipid panel, fasting glucose) 4

Pre-Diabetes and TSH Management

Monitoring Strategy

• Recheck HbA1c in 3-6 months to assess glycemic trajectory 1
• Intensify lifestyle modifications including Mediterranean or DASH diet, weight loss if indicated, and increased physical activity to address both pre-diabetes and hypertension 1
• For the slightly raised TSH, recheck TSH with free T4 in 6-12 weeks if asymptomatic, as subclinical hypothyroidism can affect cardiovascular risk and lipid metabolism 1

Cardiovascular Risk Reduction

• Given pre-diabetes, consider lipid panel assessment if not recently done, with treatment targets based on overall cardiovascular risk 1
• Emphasize sodium restriction (<2g/day), saturated fat reduction, and increased physical activity as these benefit both hypertension and pre-diabetes 1

Follow-up Timeline

• 2-4 weeks: Recheck sodium, potassium, and eGFR after any medication changes 1
• 4 weeks: Reassess seborrhoeic dermatitis response to ketoconazole 3
• 1-3 months: Monitor blood pressure control and assess need for further antihypertensive adjustment 1
• 3-6 months: Recheck HbA1c and TSH with free T4 1