Hypertensive hides diet pill cocktail
Three GPs discuss a tricky problem
Leanne is a 28-year-old mother of three who has a BMI of 45kg/m2. A routine Pill check six months ago found she had elevated blood pressure. She stopped taking the Pill and is using barrier contraception. Tests by the cardiology department have not demonstrated any underlying cause apart from her obesity. She has told the dietitian, practice nurse and you that she eats virtually nothing. Her blood pressure remains uncontrolled despite four drugs. Today Leanne's sister Shelley sees you about a respiratory infection. 'Before you prescribe anything, I'd better tell you I'm taking these,' she says, showing you packs of thyroxine, sibutramine and dexfenfluramine. 'Leanne and I have been seeing a private doctor about our weight. I've lost two stone but Leanne isn't doing so well.'
Dr Chris Hall
'I could withhold Leane's medication until she attends the surgery'
It is important to establish the facts here: is Leanne taking these medications too? Assuming she is, she should be told of the side-effects of her various medications including hypertension. She clearly has some degree of faith in her private doctor, though I have personal reservations, given sibutramine's co-administration with thyroxine (it is contraindicated in hyperthyroidism) and the hypertensive side-effects of the medications he/she has prescribed.
It is important to convince Shelley to allow me to breach her confidence and inform Leanne that her medication may be perpetuating her hypertension.
If Shelley is unwilling to acquiesce I could withhold Leanne's medication until she attends the surgery, but there is then the risk that she may just default on her antihypertensives.
It is important to discuss the efficacy of contraception with her hypertension, obesity and polypharmacy are hardly conducive to a safe pregnancy. Most GPs have been told by a patient struggling to lose weight that he/she 'eats virtually nothing'. Rather than criticising this, has the importance of exercise been discussed with Leanne? Can she fit this into her lifestyle? Three children are hard work!
In MRCGP speak, I may have to 'challenge her beliefs and attitudes' about the nature of dieting and weight loss. What the RCGP does not tell you, however, is that this can often lead to a heated exchange between doctor and patient.
There is a danger that Leanne and I will fall out with any interference in her private dietary regimen. I think that it is reasonable to point out to her that she has been less than honest with me. Each prescription I sign not only involves me taking legal responsibility for the medication prescribed, but it implies a contract with the patient. She does not seem to me to be fulfilling her side of the bargain.
Her apparent reluctance to reveal details of her other medications may have meant many unnecessary consultations and expensive investigations.
But it is in no one's interest least of all
the patient to appear overly critical. Diplomacy and tact are called for in large measure. A verbal contract and follow-up plan should be made with the patient, with regular weighing and blood pressure checks at the surgery.
Dr Nick Imm
'I'd explain I cannot condone this kind of treatment'
Although this is obviously an example of inappropriate, dangerous and probably illegal prescribing, I need to deal with it sensitively and effectively. First, Shelley has told me they both visit the private doctor, a disclosure that could be seen as a breach of her sister's confidence. But the treatment prescribed is completely unacceptable. I presume (although don't know for sure) that Leanne is talking similar medication to Shelley.
Thyroxine is not a treatment for obesity and I'm pretty sure I would have checked thyroid function in a patient with resistant morbid obesity. Dexfenfluramine was withdrawn several years ago over a link with valvular heart disease it certainly shouldn't be prescribed any more.
Sibutramine is a recognised drug for obesity but should only be used in conjunction with other measures such as dietary advice, exercise and regular weight monitoring. Unfortunately, a side-effect of sibutramine can be raised blood pressure, which won't really help Leanne. Uncontrolled hypertension is a contraindication to sibutramine.
In the first instance I'd advise Shelley her medicines were inappropriate and she should stop them. She is likely to be shocked that her private doctor could give her banned and dangerous treatments. She may well feel betrayed or foolish.
I'd be frank about the possible side-effects and explain that I cannot condone this kind of treatment. Hopefully she'll be able to persuade Leanne to come to the surgery for a similar discussion. If she feels unable to do this I'd consider breaching confidence and calling her myself since she is possibly at risk of harm.
I also have a duty to the wider community this private doctor needs to be investigated. How many other patients are being given incorrect medication without their GP's knowledge? The consequences could be disastrous. I'd take advice from my medical defence organisation and the GMC.
With luck, I'll be able to regain the confidence of these patients and start afresh.
Dr Stefan Cembrowicz
'Why has this stuff worked on her sister and not Leanne?'
'Diet clinics' now operate all over the place and seem to be able to get doctors to work in them to rubber-stamp the necessary prescriptions. As a city GP I may well have patients who are taking this sort of prescription without my knowledge. I haven't seen any surveys of what they achieve, or what the benefits and risks are. Perhaps my defence organisation and the GMC will have some interesting tales to tell if these clinics put hypertensive patients on such alarming cocktails.
Blowing a fuse because my patient is trying to help herself behind my back would be counter-productive. And why has this stuff worked on her sister and not on poor Leanne? When we next meet I will have to start again.
Getting her to stop her secret (and doubtless costly) polypharmacy will be the first thing in view of her blood pressure, and may not be difficult as it seems to work no better than my own best efforts. She has already had the standard advice lifestyle, healthy exercise without apparent effect. Why hasn't this worked?
A general review may help. Going back to GP training: what is her physical/psychological/ social profile? What is keeping her in the status quo of her obesity? On the physical side, checking her TFTs and other routine bloods (presumably done already in outpatients) would be a good first step her next stop is going to be diabetes.
Psychologically, is she depressed? As for social factors, reflect on how her sister has escaped her weight and she hasn't. Is she stuck at home with small children? What are her outside interests? Obese people may lead less outgoing lives, to the point of becoming virtually housebound. What is her partner's line on this?
Our dietitians are currently not able to see obese people, though a special case should be negotiable for Leanne, who could be described as morbidly so. Her sister may be the key to this door could I get her to go along to Weight Watchers or a similar organisation, with a view to inducing Leanne to go too?