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How can impaired glucose tolerance be managed?

Q: I am a 53 years old hypertensive man and taking Tenochlor 100 and Losar A twice daily. For the last two years my fasting blood sugar (FBS) remains consistently between 110 mg/dl and 120 mg/dl whereas my postprandial blood sugar is always normal. My HbA1c is 6.6. My glucose tolerance test (GTT) showed FBS – 114 mg/dl, first hour – 238 mg/dl and second hour – 189 mg/dl. The doctor told me that I have impaired glucose tolerance (IGT) and suggested me Glycomet 850 mg once after meal and Rosuvas 5 mg. Please advise.

A:Tenochlor contains two drugs: atenolol and chlorthalidone. Losar A also contains two medicines: losartan 50mg and amlodipine 5mg. Four anti-BP medicines are given only in exceptional cases i.e. only when lesser number of drugs are inadequate in their recommended dosage. Atenolol belongs to a class of medicines called beta-blockers. It is known that prolonged use of this class can lead to hyperglycaemia (high blood glucose levels) and ultimately diabetes. Because of this reason the British National Institute of Clinical Excellence (NISE) has changed its guidelines on the treatment of high blood pressure and placed betablockers (such as atenolol) as the last choice to be used when every thing else has failed. Chlorthalidone is a diuretic (increases the production of urine) and is known to cause high blood sugar levels and even diabetes. Thus you are taking two medicines with a potential to cause high blood sugar levels. It would not be rational to get rid of potentially serious side effects by adding one more medicine i.e. metformin. There is a need to stop Tenochlor and see if your blood pressure can be controlled with just two medicines i.e. amlodipine (sold as Amlodac) 5mg once daily and losartan (sold as Lozitan) 50mg daily. It is not a good idea to use combination products such as Losar A because dose adjustment of individual ingredients is not possible. It ought to be kept in mind that the dose range of losartan is 25 to 100mg daily while amlodipine is 2.5 to 10mg daily. A patient may need amlodipine 5mg and losartan 100mg. Such a dosage schedule is not possible with fixed-dose combination products such as Losar A. Therefore in good clinical practice one should always use medicines separately in individual doses. In your case if BP is not controlled with amlodipine and losartan, then one can add enalapril (sold as Enam) 5-10mg 1-2 times daily. As a matter of fact in young sexually active males, enalapril is the first choice since it does not lead to impotence while atenolol and chlorthalidone both can cause erectile dysfunction. Briefly speaking: Tenochlor is inappropriate in your case. Attempt should be made to use minimal medication in minimal doses to control blood pressure. At the same time mild exercise such as brisk walk for 45 minutes daily to cover at least 4.5km at least 5 times a week should be undertaken. If at all required, enalapril (Enam) can be added. After three months blood sugar measurements should be repeated and follow up action taken as per need.

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