A 45-year-old woman with type 2 diabetes mellitus, obesity, and hypertension comes to the office for a routine follow-up visit. Her medications include a sulfonylurea and ACE inhibitor. The patient has lost 2.3 kg (5 lb) and credits a new energy and weight loss supplement. She purchased the supplement over the Internet on the recommendation of a friend and believes that it contains caffeine and several herbs that promote weight loss. The patient has had no problems tolerating the supplement. Blood pressure is 140/90 mm Hg and pulse is 88/min. Which of the following is the most appropriate response by the physician?

Question

A 45-year-old woman with type 2 diabetes mellitus, obesity, and hypertension comes to the office for a routine follow-up visit.  Her medications include a sulfonylurea and ACE inhibitor.  The patient has lost 2.3 kg (5 lb) and credits a new energy and weight loss supplement.  She purchased the supplement over the Internet on the recommendation of a friend and believes that it contains caffeine and several herbs that promote weight loss.  The patient has had no problems tolerating the supplement.  Blood pressure is 140/90 mm Hg and pulse is 88/min.  Which of the following is the most appropriate response by the physician?

Quizplus · Accepted Answer

Patients commonly use herbal preparations and dietary supplements. Although the US Food and Drug Administration (FDA) regulates dietary supplements, the regulations are less strict than those for prescription and over-the-counter medications. Some herbal products have established safety and/or efficacy, but there are few quality assurances regarding the content and purity of many herbal supplements, and unknown toxic ingredients may cause adverse effects and dangerous drug interactions. For example, the herbal supplement ephedra, marketed as a diet pill and energy booster, was banned by the FDA in 2004 due to the risk of cardiovascular complications (eg, increased blood pressure, myocardial infarction, stroke). However, ephedra-containing products are still readily available through the Internet. It is important for physicians to routinely inquire about the use of these products, both to understand why patients are using them and to evaluate the risks and benefits of continued use. This patient should be supported in her weight-loss efforts and her use of supplements should not be immediately dismissed. The physician should instead assess the ingredients for contraindications or drug interactions and then provide counsel regarding the potential risks, especially given her medical history. (Choice A) Although the physician should work with the patient to develop a comprehensive weight-loss plan, including behavioral approaches to weight loss, this response is dismissive and does not take into account the use of supplements, which this patient is likely to continue taking. (Choices B and E) Supporting the patient's continued use of the supplement or merely cautioning her to avoid additional caffeine, without assessing the supplement for dangerous ingredients such as ephedra, does not adequately address safety concerns. (Choice C) The patient may interpret this response as discouraging her efforts to lose weight, negatively impacting rapport with the physician. In addition, it does not address the risks or benefits of the supplement itself. Educational objective: Physicians should routinely ask their patients about the use of herbal preparations and nutritional supplements and advise them on the quality, safety, and efficacy of these products. __________ References: Reduction in ephedra poisonings after FDA ban. (http://www.ncbi.nlm.nih.gov/pubmed/26017843) Overview of regulation of dietary supplements in the USA and issues of adulteration with phenethylamines (PEAs). (http://www.ncbi.nlm.nih.gov/pubmed/27259162) An overview of herb and dietary supplement efficacy, safety and government regulations in the United States with suggested improvements. Part 1 of 5 series. (http://www.ncbi.nlm.nih.gov/pubmed/27818322)

A 45-Year-Old Woman with Type 2 Diabetes Mellitus, Obesity, and Hypertension