Sometimes the treatment is worse than the disease

To do nothing is sometimes a good remedy.
-Hippocrates

Edna Frost is 88 years old, a slender, slow-talking woman with a dry sense of humor and a blood pressure that’s all over the place. At best, she runs ten points higher than any of her previous doctors wanted to put up with. At worst, she flirts with systolics over 200, but that doesn’t seem to be a common occurrence.

Edna has been my patient for the past three or four months. She moved up here from Georgia to live with her daughter, who retired this summer.

When I first met her, Edna didn’t mince her words:

“These medications make me sick,” she announced. “They make me tired and dizzy and sick to my stomach.”

I looked through her old medical records. She had been on everything imaginable, and nothing really controlled her blood pressure better than the three medications she came to me on, a beta-blocker, an ACE inhibitor and a diuretic.

In our first visit we agreed to cut her beta-blocker dose in half, since that one was my first suspect, even though her blood pressure didn’t drop when I asked her to stand up. The evidence today seems to favor the other two over beta-blockers as far as heart attack and stroke prevention. I asked her to bring her blood pressure cuff to her next visit, so we could compare hers and mine to make sure our readings agreed.

The second visit took place with the same symptoms, the same erratic home blood pressure readings and a good match between Edna’s blood pressure cuff and mine. I suggested we stop her beta-blocker completely. I didn’t have to ask her twice.

Our third visit came and Edna was just as tired, dizzy and nauseous as before, and her blood pressure was still all over the map. This time I asked her to stop her ACE-inhibitor.

Visit number four brought no good news, so we switched and had her stop the diuretic and restart her ace-inhibitor. I was a little apprehensive about stopping everything, given the small blood pressure spikes she seemed to have now and then.

At the fifth visit, with side effects and blood pressure readings completely unchanged, I threw in the towel and gave her permission to stop everything.

She grinned and thanked me.

Today I saw Edna back, off everything and with the same erratic home blood pressure recordings, low 140’s most of the time, 165-170 very occasionally. But she was all smiles and said, for the first time since I met her:

“I feel great!”

I wanted to make sure I had understood her correctly. “You feel better now than on any of the blood pressure medicines you have taken over the years?”

“Absolutely!” Her conviction was clear.

I took a deep breath and continued: “So far I haven’t seen the medications make any difference in your blood pressure. It’s still possible some other combination of medications might control your blood pressure better, but I can’t promise you they would be side-effect-free.”

“I’d rather leave things the way they are.”

I knew her answer before I asked: “Would you want to go without blood pressure medication, even if that means your risk of stroke or heart attack is higher than if we can bring your blood pressure down some?”

“Yes, because I don’t want to feel sick the way I did before.”

“I understand, and I admit you’ve tried just about everything”, I told her. “Actually, your blood pressure would have been called normal for someone your age thirty years ago, and the pendulum has started to swing back in that direction. Some of the journals have been writing that we are pushing older patients’ blood pressure too low and may be causing complications from low blood pressures.”

“See, you shouldn’t worry about my blood pressure!” She reached over and poked my arm.

I smiled. “Perhaps not, but I have to tell you that it may start to climb some day, and you’d need to let me know if it does.”

“Why would it?”

I explained: “Sometimes the fluid pill you were taking continues to affect a person’s blood pressure for months after they stop it.”

Surprised, she raised her eyebrows. “So, how often would you want me to check my blood pressure?”

“Twice a week.”

“I’ll do that – for you.”

“And I’d like to check it again in the office some time after New Year’s”, I said, almost expecting resistance.

“I’ll let you”, she said, already getting up from her chair.

Edna and her daughter left the office clearly relieved. Sometimes the treatment seems worse than the disease.

“A Country Doctor” is a family physician who blogs at A Country Doctor Writes:.

 

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  • Norm

    It isn’t just the recommended blood pressure levels that has been lowered over the years, so has blood glucose and cholesterol.

  • stitch

    Rule #13 of the House of God: “The delivery of good medical care is to do as much nothing as possible.”

    and good satire has more than a whiff of truth in it.

    Just try telling it to the Medicare geniuses who want to measure your outcomes based on the numbers, not on the patient – another old bromide that has unfortunately gone by the wayside but needs to be revived.

  • JGM

    Are we dealing with “benign essential” hypertension or could it be one of the other more correctable flavors such as hyperaldosteronism? Sometimes the history of previous workups is lost when patients move between physicians.

  • Gilbert Burkhardt

    I had High Blood Pressure for many years. I went through a dozen doctors and so many different medications I could have set up a new pharmacy. One medication Minoxidil caused enough hair growth I could nearly braid it on my knuckles! I finally went to a specialist at the Cleveland Clinic, and he took me off all of them but one, Spiroldactone(spelling?) and my blood pressure went down to close to normal. However in the years of taking Topril I became Diabetic. No diabetics in my family on either side 5 generations back. Taught me a lesson, go to the best first. read all medication side effects. Now I have a doc who wants me on a cholesterol medication, but the diabetic already has a chance of liver damage so I have refued it. The cholesterol is 240 and I am 55 what do you think?

  • Jeanja

    Funnily enough, I recently read a panel recommend that in cases of resistant hypertension, “assume non-compliance until proven otherwise”:

    http://www.consultantlive.com/cardiovascular-diseases/content/article/10162/1835803

    I’m reluctant to accuse patients of non-compliance. And non-compliance obviously would not cause side effects. But assume for a moment that Edna’s blood pressure spiked because she was not taking her medication. Why would she see keep visiting you (her doctor) to request to be taken off the medication she wasn’t taking anyway?

    Perhaps here’s a clue: “Edna and her daughter left the office clearly relieved.” Edna wanted her daughter to know it was okay that she wasn’t taking her medication. Her daughter may have been hassling her to take it.

    This is just a little thought experiment. I have no idea if Edna was taking her medication or not.

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