Friday, November 11, 2011

A Personal Reflection on Hypertension

After being a PA for 17 years, I thought I had learned just about everything I needed to effectively practice in an academic medicine practice.  “Yes, there was always new studies that came out, which I needed to know about, but the basis of how I practiced clinical medicine I thought was sound.” 

That was until I was diagnosed with severe hypertension, with a blood pressure reading of 170/100.  Now, I admit that’s not much to be concerned about, you treat it with anti-hypertensive medications.  The medicine is titrated to effectively bring down the blood pressure to normal levels.  After that, it’s just a matter of making sure I took the daily medicine and it continued to work.

That’s the way it’s supposed to work, right?  Only problem was, I found out I had inherited a particular gene which dictated I had one drug allergy after another.  Too many relatives, (grandmother/aunts/uncles/sister/niece) all had the same problem, you give us a prescription drug and we have an adverse side effect to it that necessitates discontinuation of it.  Between the episodes of Stephen-Johnson like syndromes with sulfa in my family members (which included myself), to a near-permanent sleep status induced by an anesthetic, we are a physician’s nightmare when we need to be treated for a medical condition. 

I should have expected to have had problems with anti-hypertensive medications, knowing my family history and my own personal history of drug allergies.  Before I had reached my 25th birthday, I was already allergic to three of the major antibiotic families. 

It had been 20 years since my last drug reaction though.  So I just didn’t think about it.  I was now at my internist office being given a prescription for an ACE inhibitor.  I thought, “Fine, I’ll deal with the ACE induced cough.”  I did and after about 3 weeks it went away.  I titrated the dose up until it kept my blood pressure within the normal range.  I had a follow-up appointment scheduled to see my internist two weeks later. 

Then my problem started.  Every time I stood up, I felt as though I was going to pass out.  No preamble, no dizziness, just pure and simple syncope.  And if I somehow managed to stay erect, it would immediately be followed by cardiac palpitations with a discernable irregular pulse. 

I told my internist what was going on, and there went the ACE inhibitor.  I was switched to a beta-blocker.  That shouldn’t have caused a problem.  Wrong!  Within just a few days of titrating up the dose to an effective level, I came down with a rip-roaring pharyngitis accompanied by a fever.  I initially thought it was just a ‘bug’ that I had caught from one of my patients.  It didn’t dawn on me to look up the side effects of my beta-blocker.  Had I done so, it would have necessitated my being discontinued from my newest anti-hypertensive medication. 

For a fever with pharyngitis upon starting a beta-blocker is listed as a true allergic reaction to the drug and stipulates that it be stopped. 

Well after a few weeks I got used to taking my new medication, and my blood pressure was under control.  Three years went by, all the while, slowly but surely my system was building itself up for an all-out assault on my beta-blocker. 

I first noticed that I had a psoariatic skin rash.  I thought to myself this is weird, but okay, I’ll take care of it with changing my shampoo.  Then I started having ocular pain.  It was so intense that when I made it into to see my opthalmologist I was on the verge of crying, if only I could have.  For I had such ocular dryness from my beta-blocker that I had no tear production at all, which is what was causing my ocular pain.  Two more medications were added to what I was already taking. 

If I had been playing baseball, my system had now scored two hits against my beta-blocker.  Two months later while I was on vacation in Europe, it scored two more to make it a home run. 

Two days into my grand Mediterranean cruise, I was in the exercise room when I noticed that my ankles had disappeared.  I pressed my finger into an ankle and immediately noticed that I had 3+ pitting pedal edema.  “Oh crap,” I thought.  Had I a PDR in front of me and read the side effects to my beta blocker I would have immediately become concerned about the 19% associated incidence of heart failure with my anti-hypertensive. 

And if that wasn’t enough, the following day I noticed a horrid rash on my legs and feet.  I thought to myself, “where did this come from?”  I had already been treating my hands with an anti-fungal cream for several weeks prior to my vacation for a presumed outbreak of seborrhea.  The cream was working on my hands, maybe it would work on this new rash.  Thankfully it kept my leg rash under wraps as long as I lathered myself in it every day. 

My system had now scored a home run.  And I finally took notice and began listening.  Once I arrived home, I was back in my internist’s office, recounting the side effects I was having and asking for a change in my meds. 

As I assumed, my internist readily agreed.  With the knowledge that it would take a week to receive my new medication (non-formulary drug request authorization had to be submitted), I began the required beta-blocker taper.  Three days into the taper, my rip-roaring pharyngitis returned only this time with laryngospasms.  I couldn’t talk, five minutes later I could, and vice versa.  The following morning I couldn’t talk at all.  My voice didn’t come back for 24 hours.  For the next several days I could palpate muscular spasticity in my neck, which was always accompanied by a horrid coughing spell. 

I was finally listening to my system, and it was saying, ‘no more beta-blocker!’  It took me two full weeks before my cough finally disappeared.  A week after visiting my internist, I received my new ant-hypertensive medication. 

I began to titrate my dose upwards.  On the second and third day I took a small dose of it and both nights I ended up with insomnia.  I also noticed the return of my pedal edema with tachycardia.

I couldn’t believe this was happening.  Two of three of these symptoms were listed as side effects to the drug.  Now what?   I didn’t feel as though I could continue on it.  I needed my sleep, walking through my days filled with seeing sick hospitalized patients/clinic patients I needed to be fully alert and coherent, having insomnia was incongruent with that. 

I was running of out options.  The only thing left was to try an alpha blocker, calcium channel blocker, or a vasodilator.  The vasodilator choice wasn’t very appealing, I thought I would probably just end up with my pitting pedal edema again.  So did I try the alpha blocker, or the calcium channel blocker next?  And what would happen if I had side effects to them?  Then what? 

While I was thinking through my options, I happened to be in a local bookstore, a favorite hideout of mine.  I could spend hours browsing through a bookstore.  I wasn’t looking for anything in particular, I don’t even know why I was scanning the medical books section.  All of sudden my eyes landed upon a book written by Mark Houston, MD.  My immediate thought was, “oh crap another book written for patients, giving them yet more ammunition to question their physician unendingly about their hypertensive medication.” 

Too many other books on the shelf were just like that, all with catchy titles, but all basically leaving the patients feeling like they may not be receiving the best medications, or the best treatments, or why aren’t they on this or that alternative medication?  It’s working for this or that book author, so why not them? 

I don’t know why I even picked up Dr. Houston’s book.  But I did.  I read his title, a Vanderbilt Medical School faculty member, the Director of their Hypertensive Center, a phi beta kappa graduate as well as having graduated AOA (alpha omega alpha, i.e. in the top 10% of his medical school class at   
Vanderbilt).  “Okay, I thought, I’ll give it to him, he at least has the right credentials.”  I cracked the book open and perused some of the chapters. 

I was familiar with some of the information contained within his book, the DASH diet, exercising, losing weight, quit smoking, limit or totally stop any alcohol intake, etc.  “Nothing new in all of that, I thought to myself, I had already been doing that.” 

I flipped to another book chapter.  Nutrition, hmm, that’s a different slant.  As I quickly scanned the chapter he was speaking about all of the various minerals and vitamins our body needs to support our vascular system.  Okay, that makes sense, it’s just basic physiology, what’s the big deal? 

Well it was basic physiology that he was applying to a rampant health problem, hypertension.  He would discuss a particular mineral or vitamin and then talk about how it applied to blood vessel vascular physiology.  His discussion of it would then immediately be followed up by study upon randomized study of how effective the nutritional supplement was in decreasing a person’s blood pressure. 

I thought to myself, “okay the studies he was discussing had to be published in journals of ‘no repute.”  No way were they published in major medical journals such as Circulation, British Medical Journal, New England Journal of Medicine.  So expecting to see some unknown journal article as references I was totally surprised to see reference upon reference for the studies as being published in major and very distinguished medical journals such as New England Journal of Medicine.

That’s when my interest became more than a little piqued.  I planked my monies down at the cashier’s and walked out with the book.  I read it through in one night’s sitting. 

I thought to myself, “okay no one is going to be the wiser to my plan.  I’ll give what he had to say about the vitamin and mineral supplements a try for one month, if they don’t make a difference in my blood pressure, then I’m the fool, and no one will ever know.” 

Well two weeks into my new plan, I started to notice a change, my pressure readings were decreasing.  And amazingly, a nice side benefit was that my hot flashes which had come every forty minutes were gone.  Hmm, was I onto something in regards to Dr. Houston’s book?

One month into my trial of the vitamins and minerals I was now taking, my blood pressure readings, which originally been upon my diagnosis in the range of 170/100 were now totally normal and stayed normal all day long and went down to 100/60 when I slept.    

I continued to take my blood pressure readings for two more weeks and every time, the same, a normal reading.  My follow-up appointment with my internist was coming up in a few days.  How would I explain what I did to him?  He’d probably have the same reaction I initially did, “yeah, right, you’re just another alternative medicine kook now!”  

  Nutrition, eating right, I came to conclude, was more than just eating a salad for dinner, or limiting my salt intake, or watching my weight.  It was  more systemic than that.  It involved eating the right foods, in the right combinations, each and every day.  It involved giving my system what it needed to physiologically function the way it should.  It involved giving it the magnesium it needed, the calcium, the vitamin C and omega fatty acids it required to function at it’s best. 

That’s when I started to think, as a group of medical providers (both physicians/PAs/NPs) our medical knowledge of nutrition is truly lacking.  How many classes during my PA program did I take in nutrition?  A big fat zero, that’s how many! 

How many times had I snubbed my nose up at a patient when they came in telling me they were on this or that vitamin or taking that alternative medicine?  Too many to count.  And it wasn’t until my own system called me up short, gave me all sorts of problems with prescriptive medications that I started on a new path of learning more about proper nutrition, and the appropriate use of vitamins/minerals our body requires. 

I thought I had basically learned clinical medicine and was comfortable in what I knew after 17 years in the field.  Well this experience taught me even more, it opened my eyes to the field of nutrition, opened my heart to learning something new, and closed the door on my judgmental attitude when it came to patients who walked into the clinic room and told me he was taking a form of some alternative medication.  Next time, I’m going to be more willing to read the medical evidence behind the supplement, and not be so quick to judge. 

Not only has my own personal health benefited from such an attitude, but so can each and every one of my future patients.


2 comments:

  1. Completely useful..good source, thanks anyway!

    ReplyDelete
  2. thanks, alvaro, I appreciate the compliment, sharon

    ReplyDelete