Brief Answer:
May be a blood sugar problem

Detailed Answer:
Hello Yaser,

I am glad to hear from you again. If you are urinating a large amount (large volume per day) and you are feeling dry (dry mouth), I am concerned that your body is not handling sugar properly. I advise that you get two blood tests for this: An A1C test and a fasting blood sugar test.

The A1C test is an approximate average of blood sugars over the past 2 months. The fasting blood sugar test shows what your blood sugar is in that moment, without any food.

If a person's blood sugar is high, such as from not producing enough insulin, then the kidneys spill the sugar into the urine and because of the high amount of solute in the urine from it (high osmotic load), water is attracted to it. This causes there to be more urine from all the water, and also causes some degree of dehydration.

I do not see any test results posted. Can you try again? Did you post them on a different day? You can try to send them by writing the support service, if the "upload reports" button isn't working.

---

Brief Answer:
May be a blood sugar problem

Detailed Answer:
Hello Yaser,

I am glad to hear from you again. If you are urinating a large amount (large volume per day) and you are feeling dry (dry mouth), I am concerned that your body is not handling sugar properly. I advise that you get two blood tests for this: An A1C test and a fasting blood sugar test.

The A1C test is an approximate average of blood sugars over the past 2 months. The fasting blood sugar test shows what your blood sugar is in that moment, without any food.

If a person's blood sugar is high, such as from not producing enough insulin, then the kidneys spill the sugar into the urine and because of the high amount of solute in the urine from it (high osmotic load), water is attracted to it. This causes there to be more urine from all the water, and also causes some degree of dehydration.

I do not see any test results posted. Can you try again? Did you post them on a different day? You can try to send them by writing the support service, if the "upload reports" button isn't working.

---

Brief Answer:
Please see discussion below

Detailed Answer:
Hello Yaser,

I took a look at all of your lab results and this is what I found to be abnormal. I will note abnormalities based on common US lab values rather than those listed for reference range on the reports.

Fasting blood sugar 120 (normal is less than 100): High
A1C 6.66 (over 6.5 is diagnostic for diabetes mellitus): High
Uric acid 9.10 (normal is 3.4 - 7): High
Chloride 95: Slightly low
Albumin (protein) in urine: 45: Slightly high

So what does this mean:
Your elevated blood sugar has crossed into the range of early diabetes. Your sugars are not extremely high, but you do meet the criteria for diabetes mellitus if your A1C was 6.66. This may be what is causing the thirst, dryness, and increased urination.

The albumin in the urine is a bit too high, and may be related to the effect of the excess sugar on your kidneys. To get a better sense of the degree of albuminuria, you can get a 24 hr urine collection for albumin, but that is not the next step I would do. I think the real issue is getting your sugars under control with diet, exercise, and medication, and the microalbuminuria may resolve.

The slightly low chloride is likely also related to the elevated sugars causing fluid loss.

Now another issue is that your blood pressure medication (which is 2 medications combined) includes a thiazide diuretic which can raise your uric acid levels (which you have), and also raise your blood sugar. So I would advise a different blood pressure medication that does not include hydrochlorothiazide or other thiazide diuretic.

I'm sure this isn't the news you wanted to hear, but the good news is that your sugars are not extremely high yet, and with weight loss, exercise, dietary modifications (decrease carbohydrates), and medication, you can get this under control.

I'd be happy to talk with you about this further, or to follow up with you after you have initiated some of these treatments/changes.

---

Brief Answer:
Please see discussion below

Detailed Answer:
Hello Yaser,

I took a look at all of your lab results and this is what I found to be abnormal. I will note abnormalities based on common US lab values rather than those listed for reference range on the reports.

Fasting blood sugar 120 (normal is less than 100): High
A1C 6.66 (over 6.5 is diagnostic for diabetes mellitus): High
Uric acid 9.10 (normal is 3.4 - 7): High
Chloride 95: Slightly low
Albumin (protein) in urine: 45: Slightly high

So what does this mean:
Your elevated blood sugar has crossed into the range of early diabetes. Your sugars are not extremely high, but you do meet the criteria for diabetes mellitus if your A1C was 6.66. This may be what is causing the thirst, dryness, and increased urination.

The albumin in the urine is a bit too high, and may be related to the effect of the excess sugar on your kidneys. To get a better sense of the degree of albuminuria, you can get a 24 hr urine collection for albumin, but that is not the next step I would do. I think the real issue is getting your sugars under control with diet, exercise, and medication, and the microalbuminuria may resolve.

The slightly low chloride is likely also related to the elevated sugars causing fluid loss.

Now another issue is that your blood pressure medication (which is 2 medications combined) includes a thiazide diuretic which can raise your uric acid levels (which you have), and also raise your blood sugar. So I would advise a different blood pressure medication that does not include hydrochlorothiazide or other thiazide diuretic.

I'm sure this isn't the news you wanted to hear, but the good news is that your sugars are not extremely high yet, and with weight loss, exercise, dietary modifications (decrease carbohydrates), and medication, you can get this under control.

I'd be happy to talk with you about this further, or to follow up with you after you have initiated some of these treatments/changes.

---

Brief Answer:
Plan

Detailed Answer:
Hello Yaser,

I like your thinking on this. Here are a few suggestions:

1. Yes, getting off the hydrochlorothiazide (hctz) is a good idea. I recommend that you monitor your blood pressure 2-3 x/week. If it starts to consistently climb up on Valsartan alone, you may need to add on another antihypertensive but from a different class than thiazides. Alternatively, going up to a higher dose on Valsartan alone may be adequate, but in general, we often see better blood pressure control with 2 meds, than 1 higher dosage med. Monitor it and work with a local doctor in Qatar.

2. About the excessive urination (polyuria): Going off the diuretic hctz will help, but since you've been on it a long time and only recently developed polyuria, it may more (or at least some) to do with hyperglycemia and diabetes. Getting your sugars under control will help. By the way, hctz also can raise blood sugars slightly, so going off of it may help with that as well.

3. Uric acid: Unless you have symptoms of gout, I would not start Zyloric right now. My reason is because hctz can elevate uric acid, and discontinuing hctz may be enough to resolve the problem. Recheck uric acid in about a month, and if no improvement, then consider the Zyloric.

4. Januvia is an ok choice. But I strongly recommend that you work with a local dr. in Qatar if going on this. My reason is that Januvia does have some side effects and contraindications. When starting it up, it can increase the risk of pancreatitis, and this risk is greater if you've ever had a history of pancreatitis. Also, it can lower your blood sugar too low, so you'd need to check in for blood sugar evaluation intermittently.

Januvia is not addictive - you can get off of it if needed.

5. Lifestyle modifications: This is the most important part of the plan, and also the hardest, because these changes must be made in such a way that they can be adopted on a rather permanent basis. Of course any significant lifestyle change is hard - we develop habits and ways we like to do things. But this will be more important than any meds. Dietary and exercise improvements can help both your hypertension and insulin resistance, causing the cells to take in the sugar where it is needed for cellular energy and getting it out of your blood stream where it is damaging your kidneys, small blood vessels, and peripheral nerves. I don't know your weight but sometimes just losing 15 lbs is enough to start to right things.

Suggestions:
1. Dietary changes: Increase vegetables (slowly increase in your diet) and decrease refined carbs (things made with white flour, sodas, food made with added sugar). Don't starve yourself or skip meals.

A visit with a local dietician/nutritionist can help you come up with meal suggestions you like and can maintain.

2. Exercise: If you don't do any now, start slowly and gradually increase. Consider a low impact exercise class, or some activity you like and can maintain, perhaps walking daily. Start at ten to fifteen min/day and increase by 5 minutes each week. Try to do this daily or at least 5 days per week. Goal of at least 30 minutes a day and shoot for 300 minutes/week eventually. Keep a log/record of this and be proud of your efforts!

I know that the lifestyle suggestions are hard, but I see that you are already thinking on taking action and I have confidence you can succeed at this!

---

Brief Answer:
Plan

Detailed Answer:
Hello Yaser,

I like your thinking on this. Here are a few suggestions:

1. Yes, getting off the hydrochlorothiazide (hctz) is a good idea. I recommend that you monitor your blood pressure 2-3 x/week. If it starts to consistently climb up on Valsartan alone, you may need to add on another antihypertensive but from a different class than thiazides. Alternatively, going up to a higher dose on Valsartan alone may be adequate, but in general, we often see better blood pressure control with 2 meds, than 1 higher dosage med. Monitor it and work with a local doctor in Qatar.

2. About the excessive urination (polyuria): Going off the diuretic hctz will help, but since you've been on it a long time and only recently developed polyuria, it may more (or at least some) to do with hyperglycemia and diabetes. Getting your sugars under control will help. By the way, hctz also can raise blood sugars slightly, so going off of it may help with that as well.

3. Uric acid: Unless you have symptoms of gout, I would not start Zyloric right now. My reason is because hctz can elevate uric acid, and discontinuing hctz may be enough to resolve the problem. Recheck uric acid in about a month, and if no improvement, then consider the Zyloric.

4. Januvia is an ok choice. But I strongly recommend that you work with a local dr. in Qatar if going on this. My reason is that Januvia does have some side effects and contraindications. When starting it up, it can increase the risk of pancreatitis, and this risk is greater if you've ever had a history of pancreatitis. Also, it can lower your blood sugar too low, so you'd need to check in for blood sugar evaluation intermittently.

Januvia is not addictive - you can get off of it if needed.

5. Lifestyle modifications: This is the most important part of the plan, and also the hardest, because these changes must be made in such a way that they can be adopted on a rather permanent basis. Of course any significant lifestyle change is hard - we develop habits and ways we like to do things. But this will be more important than any meds. Dietary and exercise improvements can help both your hypertension and insulin resistance, causing the cells to take in the sugar where it is needed for cellular energy and getting it out of your blood stream where it is damaging your kidneys, small blood vessels, and peripheral nerves. I don't know your weight but sometimes just losing 15 lbs is enough to start to right things.

Suggestions:
1. Dietary changes: Increase vegetables (slowly increase in your diet) and decrease refined carbs (things made with white flour, sodas, food made with added sugar). Don't starve yourself or skip meals.

A visit with a local dietician/nutritionist can help you come up with meal suggestions you like and can maintain.

2. Exercise: If you don't do any now, start slowly and gradually increase. Consider a low impact exercise class, or some activity you like and can maintain, perhaps walking daily. Start at ten to fifteen min/day and increase by 5 minutes each week. Try to do this daily or at least 5 days per week. Goal of at least 30 minutes a day and shoot for 300 minutes/week eventually. Keep a log/record of this and be proud of your efforts!

I know that the lifestyle suggestions are hard, but I see that you are already thinking on taking action and I have confidence you can succeed at this!

---