Physicians routinely order blood pressure (BP) medications on an as needed basis or pro re nata to control BPs in hospitalized patients. We hypothesized that treatment of inpatients, who do not have a hypertensive emergency, with the use of antihypertensive medication on an as needed basis could lead to adverse outcomes. Four thousand two hundred nineteen patients who received BP medications on an as needed basis in addition to scheduled antihypertensive medications were matched 1:1 using propensity matching to those who received only scheduled BP medications. Compared with the propensity-matched cohort, patients who received antihypertensive medications on an as needed basis were more likely to experience abrupt lowering of systolic BPs (odds ratio, 2.05 [95% CI, 1.56–2.71], P <0.001), acute kidney injury (odds ratio, 1.24 [95% CI, 1.09–1.42], P =0.002), and ischemic stroke (odds ratio, 8.5 [95% CI, 1.96–36.79]; P <0.001). The use of as needed antihypertensive medication was also associated with increased in-hospital mortality (odds ratio, 2.36 [95% CI, 1.26–4.41]; P =0.001) and an increase in the median length of stay (4.7 versus 2.9 days; P <0.001). In addition, ischemic events were more likely in those who had an abrupt drop in BPs, and the risk was increased in proportion to the number of doses of as needed BP medications administered. The use of as needed antihypertensive medication is associated with an abrupt drop in BPs, increased risk of ischemic events, in-hospital mortality, and longer length of stay. We suggest that the routine use of as needed antihypertensive medication should be discouraged.

A 67-year-old female with a relapse of multiple myeloma after being in remission for approximately 2 years following autologous stem cell transplant presented with worsening pancytopenia, over a three-month period. There were an increase in her monoclonal spike at 3.13 g/dL on serum protein electrophoresis, low serum B12 levels, and positive intrinsic factor antibodies. Three months before, she had normal B12 levels and a significantly lower monoclonal spike of 1.07 g/dL. She was diagnosed with B12 deficiency with pernicious anaemia in the setting of her worsening myeloma. Multiple myeloma (MM) has been linked with B12 deficiency and pernicious anaemia. Several mechanisms have been described regarding the pathogenesis of B12 deficiency in such patients. Increased tumour activity can further perpetuate the development of B12 deficiency in such patients. With regard to our case, the increase in tumour activity and onset of pernicious anaemia could have contributed to the rapid development of B12 deficiency. In contrast to this, rapid development of B12 deficiency could also signify relapse or worsening of the myeloma as seen in our case. Physicians ought to consider B12 deficiency in patients with worsening pancytopenia and myeloma.

No abstract