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Rapid Responses: Rapid Responses published:
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patient's choice.
- dr.manan vasenwala (20 October 2002)
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Beta blockers and the risk of neurodegenerative disorders
- Richard G Fiddian-Green (24 October 2002)
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Will adherence clinics help antihypertensive drug treatment?
- USHA NATARAJAN, LONDON,SE1 7EH (24 October 2002)
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Dynamics of decision making
- John Urquhart (27 October 2002)
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Tipping the balance in hypertension follow-uo
- Tom Lewis, Richard Woof (5 November 2002)
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dr.manan vasenwala, consultant-cardiologist(non-invasive) aligarh 202002. india
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this article may open a pandora's box. is it really practical to let patients make decision choices regarding their treatment?. a patient may refuse to take anti-hypertensives for any of the reasons cited. thereafter, there are several visits to ER for hypertensive crisis, cva, angina, mi and all attendant complications, the cost could run into millions. it is fair for the patient to opine about the treatment of hypertension, but would he be responsible for the escalated costs his decision may entail? what if a group of people refuse vaccinations, this will bring to nought the entire country's preventive medicine. in my practice too, i have informed patients who opt for alternative medicine for such condition as IDDM. it is not long before they present with diabetic coma. at this juncture, everyone including relatives, want allopathic treatment which would include infusion of insulin, iv fluids and repeated investigations of blood sugar u&e and name it.of course the patient have to pay for it as in india nothing comes free! |
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Richard G Fiddian-Green, None None
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If I were a young adult being asked to take a beta blocker to prevent the cardiac and cerebral complications of hypertension I would be most concerned that the drug would increase the likelihood of my developing Alzheimer’s, Parkinson’s and/or an unknown neurodegenerative disorder in years to come. The Gibbs-Ng model for memory, derived from data generated from the avoidance model in one-day-old chicks, implicates glycogenolysis and oxidative phosphorylation (1,2). One way of preventing the development of memories in the avoidance model in the one-day-old chick is to administer an inhibitor of glyocogenolysis, such as a beta blocker. The effect is apparent in humans. In one study participants treated with propranolol had slightly fewer correct responses to questions at 3 months (33 +/- 3 [mean +/- SD] relative to 34 +/- 2 with placebo, P = 0.02) and slightly more errors of commission at 3 months (4 +/-5 versus 3 +/- 3, P = 0.04) and at 12 months (4 +/- 4 versus 3 +/- 3, P = 0.05) (3). There is, furthermore, a case report from the department of neurology at the Massachusetts General Hospital of a patient who developed an amnestic syndrome, similar to Alzheimer’s, with propranolol toxicity (4). These findings raise the possibility that the long term administration of propranolol might cause an Alzheimer’s-like state. The possibly of developing a neurodegenerative disorder might be increased by being asked to take a statin to lower the blood cholesterol, for statins reduce mitochondrial coenzyme Q (5). Any other factor that compromises the adequacy of mitochondrial oxidative phosphorylation might increase the likelihood of these medications causing a neurodegenerative disorder. The uncoupler dinitropheol, for example, prevents the development of memories in the one-day-old chick model. Other uncouplers include most halogenated and nitrophenols such as those found in insecticides, ascaricides, molluscicides, herbicides, common medications such as dicoumarol, and even inhalation anaesthetic agents such as halothane. Energy transfer inhibitors include oligomycin. Inhibitory uncouplers include DDT, ditnitrophenol again, clorodiene and some insecticides. Cytokines putatively released by viral infections, lipopolysaccharide, sepsis, devitalised tissues and blood transfusions, may also uncouple oxidative phosphorylation (6). The real danger is likely to lie in the mixing of agents capable of impairing mitochondrial oxidative phosphorylation (7). If patients choose to take beta blockers and statins to reduce the likelihood of them developing cardiac and cerebral complications perhaps they should consider also taking coenzyme Q and other micronutients that are likely to enhance mitochondrial function (8). 1. Ng KT, Regan C, O'Dowd B. Astrocyte involvement in learning. In Glial cells: their role in behavior. Laming PR, Sykova T, Reichenbach A, Hatton GI, Bauer H eds. Cambridge Univeristy Press 1998, pp 315-38. 2. Daisley JN, Rose SP. Amino Acid Release from the Intermediate Medial Hyperstriatum Ventrale (IMHV) of Day-Old Chicks Following a One-Trial Passive Avoidance Task. Neurobiol Learn Mem. 2002 Mar;77(2):185-201. 3. Perez-Stable EJ, Halliday R, Gardiner PS, Baron RB, Hauck WW, Acree M, Coates TJ. The effects of propranolol on cognitive function and quality of life: a randomized trial among patients with diastolic hypertension. Am J Med. 2000 Apr 1;108(5):359-65. 4. Fisher CM. Amnestic syndrome associated with propranolol toxicity: a case report. Clin Neuropharmacol. 1992 Oct;15(5):397-403. 5. Fiddian-Green RG. Might statins cause Parkinsons? bmj.com, 18 Oct 2002 6. Fiddian-Green RG Mitochondrial considerations bmj.com/cgi/eletters/325/7367/735/a#26019, 4 Oct 2002 7. Fiddian-Green RG The real danger is in the mixing? bmj.com/cgi/eletters/325/7367/736/c#26113, 7 Oct 2002 8. Misner BD. Coenzyme Q-10 Repletion bmj.com, 18 Oct 2002 |
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USHA NATARAJAN, specialist registrar in GU &HIV LYDIA DEPARTMENT,ST.THOMAS' HOSPITAL,LAMBETH PALACE ROAD,, LONDON,SE1 7EH
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Editor- It is well known that patient factors contribute a lot towards the treatment in chronic conditions like asthma,diabetes, heart disease and HIV(Human immunodeficieny disease).Their beliefs about health and illness, in particular about medication and the impact it has on the illness are crucial.Horne R and Fisher et al have discussed "The perception of HIV and HAART"(Highly active antiretroviral treatment) as barrier to adherence, 5th AIDS impact,Brighton,2001,abstract 105. In a chronic disease like HIV where a life long commitment to taking drugs is important and especially where 100% adherence is preferred,understanding patients perceptions to the disease and treatment plays a major role in their adherence and indirectly to the success of the therapy. Failure to appreciate this important fact has resulted in the development of drug resistance and eventual failure.Many of these situations can be avoided if the clinicians explore the patient's views and beliefs and then start the treatment.The time spent on counselling is well invested.There are a lot of adherence support clinics run by the pharmacists and nurses which help in understanding, educating and influencing their knowledge.Maybe similar clinics for patients with hypertension can contribute to some improvement in the current situation. |
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John Urquhart, Professor of Pharmacoepidemiology Dept of Epidemiology, Maastricht University, PO Box 616, 6200MD Maastricht, Netherlands
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It would be helpful to learn from the authors how much time elapsed between the study patients' first receipt of advice to start antihypertensive drug treatment, and when they arrived at a decision to accept or not the advice. It would also be helpful to learn the proportion of patients who initiated treatment and then shortly changed their decision and stopped treatment. |
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Tom Lewis, Foulkes Foundation Fellow Selly Oak Hospital, Birmingham, B29 6JD, Richard Woof
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Editor, Benson and Britten’s article (1) examining why patients choose to take medication for hypertension exposes the ambivalence some people feel about pharmaceutical intervention for chronic disease. We have recently completed a study looking at the reasons a significant proportion of diagnosed hypertensives fail to return for follow-up appointments. We identified 35 such non-returners in three general practice populations in Worcester, Droitwich and Exmouth (approximately 5% of the hypertension registers). Eleven of these patients (age 30-75, median age 62, 6 male, 5 female) were interviewed in their homes and asked their views on their diagnosis, follow-up and treatment options. Transcripts were analysed using standard qualitative techniques. Many of the themes we identified fit well with those described, notably the dislike of medication and fear of being labelled as sick. We also noted that many of the patients had wider concerns about how regular follow-up would affect their perception by others. This includes worries that they would be seen as a hypochondriac not only by other patients (“Well the other people in the waiting room might think that silly old fool sitting there, there’s nothing wrong with them.”), but also by the GP (“It may not be recorded that someone’s told you to come in. They might think, ‘He comes down here every 3 months and its always normal, why does he do it. You know, he just likes to come in.’ ”). There were concerns that this might influence future treatment for other, more ‘serious’ conditions (“If I was down there every week then she’d start thinking you know, let’s give him some placebo.”) Nonetheless, all patients understood their diagnosis, although this was countered by varying degrees of denial, and agreed that medical intervention was appropriate given the severity of the possible consequences of untreated hypertension. This study, along with that of Benson and Britten, highlights some of the dilemmas patients face when attempting to resolve conflicting ideas regarding medical advice. Rather than considering such patients as non-compliant, it might be more constructive to think of them as sitting on a decision seesaw. The use of alternative consultation options and the adoption of more patient centered approaches, in particular having a greater understanding of health beliefs, may then be a way of tipping the balance towards regular follow- up and effective treatment. 1. John Benson and Nicky Britten BMJ 2002; 325: 873 Tom Lewis
Richard Woof
Department of General Practice, University of Birmingham B15 2TT Competing interests: None declared |
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