A 42-year-old woman comes to the office for evaluation of weight management. The patient notes that she has not been able to lose any weight despite making dietary changes and exercising 3 times a week for the past 6 months. She is planning to start taking ephedra, an herbal supplement containing ephedrine, that she purchased online to assist with weight loss. The risks of ephedra are discussed, and the patient is advised not to take the supplement. Prescription weight loss medications are reviewed, but the patient declines, stating that she would like to first try ephedra because many of her friends have had sustained weight loss with the supplement. Medical history is otherwise noncontributory. Vital signs are normal. BMI is 36 kg/m². Physical examination shows obese habitus but is otherwise normal. Which of the following is the most appropriate statement?

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This patient is planning to take a weight loss supplement (ie, ephedra) that can cause significant cardiovascular toxicity (eg, hypertension, stroke). Dietary supplements containing ephedrine are banned in the United States, although patients are occasionally able to obtain them from international and online sources. In addition to toxicity concerns, such nonstandard medications are often produced under unstandardized manufacturing practices, which may be associated with significant variation in the quantity and purity of the active ingredient and possible adulteration. When discussing a patient's use of nonstandard therapies that are known to be harmful, the physician should clearly explain the risks to the patient. However, despite the risks, some patients are insistent to proceed with such treatments, often based on anecdotal reports or testimonials. In such cases, the physician should respect patient autonomy, understanding and acknowledging the patient's motivations for taking the therapy. The physician should continue to be involved in the patient's care to monitor for toxicity (eg, elevated blood pressure) and develop a stronger therapeutic alliance (Choice A). Frequent follow-up is often helpful, and in time, the patient may come to better trust the physician's advice and discontinue the harmful therapy. (Choices B and E) Offering standard obesity treatment or consulting a specialist provider may eventually lead to use of safer, more appropriate therapies. However, this patient has already stated a commitment to using a potentially harmful treatment, and close follow-up should be provided to monitor for severe toxicity. (Choice D) The physician should carefully document in the patient's chart that the risks of the patient's intended treatment have been explained and that continued care to monitor for toxicity is needed. However, asking the patient to sign a written consent or waiver is not necessary because the physician is neither providing nor advocating for the treatment. Educational objective: When discussing a patient's use of nonstandard therapies that are known to be harmful, the physician should clearly explain the risks to the patient. If the patient insists on using such therapies, the physician should schedule close follow-up to strengthen the therapeutic alliance and monitor for toxicity. References: Common herbal dietary supplement-drug interactions. (http://www.ncbi.nlm.nih.gov/pubmed/28762712) Online marketing of ephedra weight loss supplements: labeling and marketing compliance with the U.S. Food and Drug Administration ban on ephedra. (http://www.ncbi.nlm.nih.gov/pubmed/33979529)

A 42-Year-Old Woman Comes to the Office for Evaluation of Weight