A 55-year-old morbidly obese woman comes to the office for a follow-up visit. The patient was recently diagnosed with diabetes mellitus type 2. Her other medical problems include hypertension and hyperlipidemia. She does not use tobacco, alcohol, or illicit drugs. Examination shows no abnormalities. Her weight is 101 kg (223 lb), 4 lb (1.8 kg) more than at her last visit. The patient admits to not following a diabetic diet as she always feels hungry. She also missed her previous appointment 2 months ago. The patient says she recently purchased ma huang (ephedra), a Chinese herb for weight loss, via the Internet after it helped a friend lose 9.1 kg (20 lb). She says, "I am really excited because I think I have already lost 2 lb after taking it for only a week. Nothing else has helped me lose weight." The physician educates the patient about ma huang's safety risks and recommends that she stop taking it, but she insists on continuing. Which of the following is the most appropriate course of action regarding this patient?

Question

A 55-year-old morbidly obese woman comes to the office for a follow-up visit.  The patient was recently diagnosed with diabetes mellitus type 2.  Her other medical problems include hypertension and hyperlipidemia.  She does not use tobacco, alcohol, or illicit drugs.  Examination shows no abnormalities.  Her weight is 101 kg (223 lb), 4 lb (1.8 kg) more than at her last visit.  The patient admits to not following a diabetic diet as she always feels hungry.  She also missed her previous appointment 2 months ago.  The patient says she recently purchased ma huang (ephedra), a Chinese herb for weight loss, via the Internet after it helped a friend lose 9.1 kg (20 lb).  She says, "I am really excited because I think I have already lost 2 lb after taking it for only a week.  Nothing else has helped me lose weight."  The physician educates the patient about ma huang's safety risks and recommends that she stop taking it, but she insists on continuing.  Which of the following is the most appropriate course of action regarding this patient?

Quizplus · Accepted Answer

Explanation: The use of herbal preparations is widespread, and physicians should routinely inquire about their consumption. Although the safety and efficacy of some herbal medications are established, others are unsafe and may cause dangerous drug interactions. Patients must be educated about these issues and made to understand that "natural" does not necessarily mean "safe." The United States Food and Drug Administration (FDA) regulates dietary supplements, but the regulations are less strict than those for prescription or over-the-counter medications. Patients should be counseled to avoid herbal products if there are concerns about their efficacy, safety, and quality. In this case, the patient is using ma huang (ephedra), a Chinese herbal supplement used for weight loss and banned by the FDA in 2004 due to the risk of cardiovascular complications (eg, increased blood pressure, myocardial infarction, stroke). The best approach is to explain the safety risks and then document counseling the patient to avoid ephedra and her refusal to do so. Documenting the recommendation to stop using the herb is essential for protecting the physician from liability in the event of an adverse outcome. It is also important to maintain the physician-patient relationship and follow the patient closely to monitor for adverse effects. (Choice A) Ma huang sold over the Internet may contain other dangerous and unknown substances, but even pure ma huang is dangerous. The patient should be counseled to stop using it whatever the source. (Choice C) The patient's decision to take ephedra against medical advice is not a reason to terminate the physician-patient relationship, just as a physician would not abandon a patient who habitually smokes cigarettes or uses illicit drugs despite counseling. After documenting the patient's refusal to discontinue ephedra, the physician should continue to help her understand the health risks involved, monitor and treat any medical complications, and encourage alternate treatment strategies. (Choices D and E) The physician must clearly recommend discontinuing ma huang due to safety concerns. Referral to an alternative medicine specialist would be appropriate only if the patient was motivated to try supplements with established efficacy and safety. Educational objective: When a patient decides to take herbal medications against medical advice, the discussion and patient's decision should be documented in the chart. The physician should follow the patient's health status and not abandon the patient despite this decision. References: Toxicity of weight loss agents. (http://www.ncbi.nlm.nih.gov/pubmed/22351299) Safety of ephedra and related anorexic medications. (http://www.ncbi.nlm.nih.gov/pubmed/18983221) Overview of regulation of dietary supplements in the USA and issues of adulteration with phenethylamines (PEAs). (http://www.ncbi.nlm.nih.gov/pubmed/27259162)

A 55-Year-Old Morbidly Obese Woman Comes to the Office for a Follow-Up