What is the management plan for a 52-year-old patient with a history of Non-ST-Elevation Myocardial Infarction (NSTEMI), atrial fibrillation with rapid ventricular response, impaired left ventricular function (Left Ventricular Ejection Fraction (LVEF) 45%), acute kidney injury (Impaired Renal Function), urinary tract infection, depression with suicidal ideation, diabetes, and hypertension, currently taking aspirin, Eliquis (apixaban), metoprolol, Jardiance (empagliflozin), and glipizide, with elevated blood pressure and symptoms of vomiting and gagging?

From the Guidelines

The patient requires immediate and comprehensive management of his multiple medical conditions, prioritizing his cardiac, diabetic, and renal health, as well as his mental well-being, to prevent further morbidity and mortality. Given his complex medical history, including NSTEMI, atrial fibrillation with rapid ventricular response, impaired left ventricular function (LVEF 45%), acute kidney injury, and diabetes, along with his recent episode of uncontrollable vomiting and current symptoms of persistent gagging, it is crucial to address each condition simultaneously. For his atrial fibrillation, the 2024 ESC guidelines for the management of atrial fibrillation 1 recommend optimal treatment according to the AF-CARE pathway, which includes comorbidity and risk factor management, avoiding stroke and thromboembolism, reducing symptoms by rate and rhythm control, and evaluation and dynamic reassessment. His current dual therapy with aspirin and Eliquis, along with metoprolol for rate control, is appropriate, and the scheduled follow-up with Dr. Strefling in two weeks will be essential for reassessing his cardiac condition and adjusting his treatment plan as necessary, considering the guidelines' emphasis on dynamic evaluation and the potential need for rhythm control strategies as outlined in the 2013 ACCF/AHA guideline for the management of heart failure 1. For diabetes management, the patient is on Jardiance and glipizide with relatively stable blood sugar readings, and he needs medication refills. The 2023 consensus recommendations for sick day medication guidance for people with diabetes, kidney, or cardiovascular disease 1 suggest that patients should receive instructions for more frequent self-monitoring of blood glucose and consider electrolyte replacement solutions to reverse volume depletion or dehydration and avoid hypoglycemia or ketoacidosis, which is particularly relevant given his recent vomiting episode. His acute kidney injury necessitates careful management, including follow-up with Dr. Patel (Nephrology) in two weeks, and his hypertension, currently elevated likely due to not taking medication because he hasn't eaten, should be addressed by ensuring he takes his antihypertensive medication with food. The patient's persistent gagging, even when drinking water, following an ER visit for uncontrollable vomiting, requires immediate attention to prevent dehydration and electrolyte imbalances, and exploring financial assistance options for his ophthalmology appointment is crucial for improving compliance with essential diabetic care components. Immediate recommendations include:

• Refilling his diabetes medications
• Addressing his persistent gagging symptoms
• Ensuring he takes his antihypertensive medication with food
• Exploring financial assistance options for his ophthalmology appointment
• Close monitoring of his cardiac, renal, and diabetic conditions, with adjustments to his treatment plan as necessary based on the latest guidelines and his clinical response.

From the FDA Drug Label

Patients treated with JARDIANCE who present with signs and symptoms consistent with severe metabolic acidosis should be assessed for ketoacidosis regardless of presenting blood glucose levels, as ketoacidosis associated with JARDIANCE may be present even if blood glucose levels are less than 250 mg/dL If ketoacidosis is suspected, JARDIANCE should be discontinued, patient should be evaluated, and prompt treatment should be instituted. Consider temporarily discontinuing JARDIANCE in any setting of reduced oral intake (such as acute illness or fasting) or fluid losses (such as gastrointestinal illness or excessive heat exposure); monitor patients for signs and symptoms of acute kidney injury. JARDIANCE causes intravascular volume contraction [see Warnings and Precautions (5. 1)] and can cause renal impairment [see Adverse Reactions (6. 1)].

The patient is experiencing vomiting and gagging, which may lead to dehydration and reduced oral intake. Given the patient's history of acute kidney injury and current use of JARDIANCE, it is recommended to temporarily discontinue JARDIANCE to prevent further renal impairment. The patient should be monitored for signs and symptoms of acute kidney injury and ketoacidosis.

• Key considerations:
  • Patient's history of acute kidney injury
  • Current use of JARDIANCE
  • Symptoms of vomiting and gagging
  • Risk of dehydration and reduced oral intake
• Recommended action: Temporarily discontinue JARDIANCE and monitor patient for signs and symptoms of acute kidney injury and ketoacidosis 2 2.

From the Research

Patient's Current Condition

• The patient is a 52-year-old with a history of NSTEMI, atrial fibrillation with rapid ventricular response, impaired left ventricular function (LVEF 45%), acute kidney injury, and urinary tract infection.
• The patient has been experiencing depression and had positive suicidal ideation without a specific plan during the last office visit.
• The patient reports feeling much better after communication with the STAR Care team and denies any suicidal or homicidal ideation.

Medications and Conditions

• The patient is currently taking dual therapy with aspirin and Eliquis for his cardiac conditions, along with metoprolol for rate control.
• The patient has a cardiology appointment scheduled with Dr. Strefling in two weeks.
• The patient is taking Jardiance and glipizide for diabetes and reports stable blood sugar readings.
• The patient has an appointment with Dr. Patel for nephrology follow-up in two weeks.

Current Concerns

• The patient recently visited the ER due to inability to stop vomiting and reports feeling better but still experiences gagging when drinking water.
• The patient's blood pressure is elevated during today's office visit, possibly due to not taking medication before eating.

Nausea and Vomiting Management

• According to 3, a practical 5-step approach to nausea and vomiting includes defining the patient's symptoms, determining whether symptoms are acute or chronic, considering medication or toxin adverse effects, formulating a differential diagnosis, and directing treatment based on knowledge of neurotransmitters and receptors involved in the emetic pathways.
• 4 suggests that acute nausea and vomiting can be treated symptomatically without extensive evaluation, while chronic nausea and vomiting requires a careful history and physical examination to guide the initial evaluation and narrow the differential diagnosis.
• 5 describes the main pathophysiological processes involved in the development of symptomatic nausea and vomiting and gives an overview of how common antiemetic drugs function to alleviate symptoms.
• 6 provides guidance on the choice of antiemetic drug based on the cause of nausea and vomiting, with serotonin and neurokinin antagonists being effective for chemotherapy-induced nausea and vomiting, and metoclopramide and antihistamines being first-line options for nausea and vomiting in pregnancy.
• 7 recommends a case-based approach to evaluating nausea and vomiting, with a focus on history and physical examination to determine the likely cause and guide further evaluation and treatment.