What is the best course of action for a patient presenting with swollen feet, who is a smoker and currently taking Allegra (fexofenadine)?

Immediate Assessment for Swollen Feet in a Smoker on Allegra

You must immediately perform a comprehensive vascular and cardiac assessment, as this patient's smoking status places them at very high risk for peripheral arterial disease (PAD) and heart failure—both life-threatening conditions that commonly present with lower extremity edema.

Critical Initial Evaluation

Vascular Assessment (Priority #1)

• Assess pedal pulses bilaterally (dorsalis pedis and posterior tibial arteries), check for capillary refill time, rubor on dependency, pallor on elevation, and venous filling time 1
• Ask specifically about claudication symptoms: leg fatigue, pain with walking that improves with rest, or any decreased walking speed 1
• If pulses are diminished or absent, or if claudication symptoms are present, refer immediately for ankle-brachial index (ABI) testing 1
• Smoking substantially increases the risk of death, MI, and amputation in PAD patients, making this assessment urgent 2

Cardiac Assessment (Priority #2)

• Evaluate for heart failure symptoms: orthopnea, paroxysmal nocturnal dyspnea, exercise intolerance, or recent changes in activities of daily living 1
• Patients may present with leg or abdominal swelling as their primary symptom of heart failure, with exercise intolerance occurring so gradually it goes unnoticed 1
• Assess volume status and weight at this visit and compare to baseline if available 1

Diabetes Screening (Priority #3)

• Screen for diabetes if not already done, as diabetic neuropathy combined with smoking dramatically increases risk for foot complications 1
• If diabetic, perform neurological assessment with 10-g monofilament testing plus at least one other test (pinprick, temperature, vibration, or ankle reflexes) 1

Smoking Cessation Intervention (MANDATORY)

The American Heart Association strongly recommends immediate smoking cessation interventions for all patients with vascular disease or at risk for vascular disease (Class I recommendation). 2

Immediate Actions:

• Offer pharmacologic therapy today: Varenicline is first-line unless contraindicated; if depression is present, use bupropion plus nicotine replacement therapy 3
• The patient with claudication (if present) is uniquely motivated to quit because leg symptoms may improve and smoking cessation prevents disease progression 3
• Continued smoking substantially increases the risk of procedural failure, disease progression, death, MI, and amputation 2, 3

Allegra (Fexofenadine) Considerations

• Fexofenadine is used for allergic rhinitis and chronic idiopathic urticaria, not for edema 4, 5, 6
• This medication is NOT causing the swollen feet—fexofenadine has a safety profile similar to placebo with no association with edema 5, 6
• Continue the medication as prescribed for its intended indication 5

Differential Diagnosis Workup

If vascular assessment is normal:

• Consider venous insufficiency, lymphedema, medication side effects from other drugs (not Allegra), renal disease, or hepatic disease
• Obtain basic labs: BMP (renal function), liver function tests, urinalysis for proteinuria 1

If PAD is confirmed:

• Establish cardiovascular risk reduction with LDL goal <70 mg/dL given "very high-risk" category 3
• Consider revascularization if severe lifestyle-limiting claudication is present 2

Common Pitfalls to Avoid

• Do not attribute edema to Allegra—this is not a known side effect and will delay diagnosis of serious underlying conditions 5, 6
• Do not defer smoking cessation counseling—this is the single most important intervention you can provide today with the largest potential benefit 3
• Do not assume bilateral edema rules out PAD—PAD can be bilateral and smoking dramatically increases risk 2, 3
• Do not skip the pulse examination—this simple bedside test can identify life-threatening vascular disease 1

Immediate Next Steps

1. Complete vascular and cardiac physical examination today 1
2. Initiate smoking cessation pharmacotherapy (varenicline or bupropion + NRT) 2, 3
3. Order ABI if any vascular concerns (abnormal pulses, claudication symptoms) 1
4. Screen for diabetes if not previously done 1
5. Arrange close follow-up within 1-2 weeks to reassess symptoms and smoking cessation progress 2