The Prescription Pitfall that Presented as Tetany
Location
D.P. Culp Center Ballroom
Start Date
4-5-2024 9:00 AM
End Date
4-5-2024 11:30 AM
Poster Number
123
Name of Project's Faculty Sponsor
Sharlet Slough
Faculty Sponsor's Department
Internal Medicine
Competition Type
Competitive
Type
Poster Presentation
Presentation Category
Health
Abstract or Artist's Statement
The Prescription Pitfall that Presented as Tetany Adam Wiley MD, David Berry DO, Sharlet Slough DO Department of Internal Medicine Quillen College of Medicine, East Tennessee State University, Johnson City, TN Introduction: Electrolyte imbalance is a common phenomenon, that can disrupt bodily functions and even cause life-threatening complications. Of the electrolyte abnormalities, hypomagnesemia is present in approximately 2.5% to 15% of the general population. It is typically associated with decreased oral intake, gastrointestinal losses, or renal loss. We present a severe case of hypomagnesemia resulting from concomitant use of esomeprazole and hydrochlorothiazide. Case: A 65-year-old woman with an unknown medical history presented to the emergency department with complaints of muscle spasms, paresthesia, and recent falls. The patient had been in her usual state of health one week prior until she developed low back pain while doing light chores. She continued to have muscle spasms, resulting in significant tetany, causing her to seek medical attention. Associated symptoms included generalized weakness, fatigue, anorexia, nausea, and vomiting. On admission, she presented with severe carpopedal spasms in the bilateral upper extremities. Physical exam revealed +Trousseau’s sign. Labs were notable for a magnesium of 0.73 (1.6-2.4mmol/L), ionized calcium of 0.73 (1.13-1.32mg/dL), and potassium of 3.1 (3.5-5.0mmol/L). EKG was significant for atrial fibrillation with rapid ventricular response. Given the severe electrolyte derangement, IV electrolyte replacement therapy was immediately initiated. This included magnesium sulfate, calcium gluconate, and potassium chloride. Her symptoms resolved soon after electrolyte repletion. Initial lab work included parathyroid hormone (PTH), vitamin D, and urine electrolytes. The workup revealed inappropriately low-normal PTH, implicating hypomagnesemia as the underlying driver. Medication review was notable for concurrent use of esomeprazole and hydrochlorothiazide (HCTZ) likely leading to magnesium depletion. She was monitored over the next few days, and her electrolytes were corrected as needed. The proton pump inhibitor (PPI) and thiazide diuretic were discontinued, and she was discharged on oral electrolyte supplementation with plans for close follow-up with primary care. Discussion: Magnesium is a key component of various physiological processes within the human body, influencing cellular function, nerve conduction, and overall well-being. Common symptoms of hypomagnesemia include fatigue, cardiac arrhythmias, tetany, and seizures. Symptoms are often linked to simultaneous hypocalcemia due to hypomagnesemic hypoparathyroidism. In our case the patient had been taking OTC esomeprazole and was recently initiated on HCTZ, likely resulting in the tipping point leading to her admission. This case reiterates the importance for clinicians to consider PPIs as a cause of electrolyte imbalance, which may be exacerbated with the addition of diuretic therapy. Furthermore, patients should be educated on the signs and symptoms of electrolyte imbalance when prescribed medications that increase risk, as it may lead to earlier discontinuation of the medication and limit unnecessary hospitalization. Conclusion: The risk of electrolyte imbalance associated with PPI increases with concurrent diuretic use. The risk of electrolyte imbalance associated with PPI increases with concurrent diuretic use. Patients prescribed diuretics may be unaware of the higher risk of electrolyte imbalance when self-medicating with over the counter PPIs.
The Prescription Pitfall that Presented as Tetany
D.P. Culp Center Ballroom
The Prescription Pitfall that Presented as Tetany Adam Wiley MD, David Berry DO, Sharlet Slough DO Department of Internal Medicine Quillen College of Medicine, East Tennessee State University, Johnson City, TN Introduction: Electrolyte imbalance is a common phenomenon, that can disrupt bodily functions and even cause life-threatening complications. Of the electrolyte abnormalities, hypomagnesemia is present in approximately 2.5% to 15% of the general population. It is typically associated with decreased oral intake, gastrointestinal losses, or renal loss. We present a severe case of hypomagnesemia resulting from concomitant use of esomeprazole and hydrochlorothiazide. Case: A 65-year-old woman with an unknown medical history presented to the emergency department with complaints of muscle spasms, paresthesia, and recent falls. The patient had been in her usual state of health one week prior until she developed low back pain while doing light chores. She continued to have muscle spasms, resulting in significant tetany, causing her to seek medical attention. Associated symptoms included generalized weakness, fatigue, anorexia, nausea, and vomiting. On admission, she presented with severe carpopedal spasms in the bilateral upper extremities. Physical exam revealed +Trousseau’s sign. Labs were notable for a magnesium of 0.73 (1.6-2.4mmol/L), ionized calcium of 0.73 (1.13-1.32mg/dL), and potassium of 3.1 (3.5-5.0mmol/L). EKG was significant for atrial fibrillation with rapid ventricular response. Given the severe electrolyte derangement, IV electrolyte replacement therapy was immediately initiated. This included magnesium sulfate, calcium gluconate, and potassium chloride. Her symptoms resolved soon after electrolyte repletion. Initial lab work included parathyroid hormone (PTH), vitamin D, and urine electrolytes. The workup revealed inappropriately low-normal PTH, implicating hypomagnesemia as the underlying driver. Medication review was notable for concurrent use of esomeprazole and hydrochlorothiazide (HCTZ) likely leading to magnesium depletion. She was monitored over the next few days, and her electrolytes were corrected as needed. The proton pump inhibitor (PPI) and thiazide diuretic were discontinued, and she was discharged on oral electrolyte supplementation with plans for close follow-up with primary care. Discussion: Magnesium is a key component of various physiological processes within the human body, influencing cellular function, nerve conduction, and overall well-being. Common symptoms of hypomagnesemia include fatigue, cardiac arrhythmias, tetany, and seizures. Symptoms are often linked to simultaneous hypocalcemia due to hypomagnesemic hypoparathyroidism. In our case the patient had been taking OTC esomeprazole and was recently initiated on HCTZ, likely resulting in the tipping point leading to her admission. This case reiterates the importance for clinicians to consider PPIs as a cause of electrolyte imbalance, which may be exacerbated with the addition of diuretic therapy. Furthermore, patients should be educated on the signs and symptoms of electrolyte imbalance when prescribed medications that increase risk, as it may lead to earlier discontinuation of the medication and limit unnecessary hospitalization. Conclusion: The risk of electrolyte imbalance associated with PPI increases with concurrent diuretic use. The risk of electrolyte imbalance associated with PPI increases with concurrent diuretic use. Patients prescribed diuretics may be unaware of the higher risk of electrolyte imbalance when self-medicating with over the counter PPIs.