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By Rachel Hall, MRPharmS
Over the years I have certainly had some tricky patients. Often they have been in denial about their diagnosis of, say, type 2 diabetes or hypertension or not wanting to take medicines when they are clearly indicated. Male patients seem less willing to accept there is anything wrong with them.
It can take a long time to turn this around in a consultation and negotiate a plan to move forward with something they agree with. There’s little point saying "here you go, take these tablets" if you know they will go away and never get the prescription dispensed. When patients admit they are not keen on taking tablets, I believe it’s important to explore other options. But when this isn’t possible, it is necessary to present the facts about what is going on and what will happen if the condition is not treated.
Only last month I saw a chap in his 40s who had been diagnosed with hypertension three years previously. He had been started on ramipril then stopped it after a short time because of stomach upset and tiredness. He only came back to the surgery recently in response to a letter calling him in for his annual hypertension check.
His blood pressure was around 150/100mmHg. Fortunately, he has not yet developed any end organ damage. He was referred to me and told me he felt fine and much better without the medicine. I explained that high blood pressure is often asymptomatic but puts him at a high risk of a stroke, heart attack or kidney damage. He still didn’t seem concerned and proceeded to tell me he would be OK, because he didn’t smoke or drink alcohol and his diet was "healthy". When I questioned him about his diet, it turned out he lived on convenience foods such as soups and ready meals. He hardly ate any fruit or vegetables. He worked long hours and rarely did any exercise. I gave him some dietary advice with some written information and he slowly started to realise that he wasn’t so "healthy" after all.
It was, I have to say, hard work — but eventually he agreed to try a low dose of an antihypertensive, with the condition that if he lost weight (his body mass index was 34) and his blood pressure reduced significantly we could try stopping it in the future. His main worry was that he would have to take these tablets for the rest of his life and with his first experience of blood pressure drugs giving him side effects I really couldn’t blame him for being reluctant to try again.
I emphasised that I had given him a completely different class of drug and a low dose, advising him that if he didn’t tolerate them this time to let me know as soon as possible so I could prescribe an alternative. I tried to reassure him that there are many different medicines to treat high blood pressure and that the first one doesn’t always suit.
It’s certainly quite common for people with hypertension to stop treatment, because often they feel better without the tablets. It is up to us as clinicians to find the right medicines for these patients and make sure they understand there are other options available.
Trying to engage your patients to find out their worries and beliefs is so important; it does take time but it is worth it in the end.
Rachel Hall is clinical pharmacist at the Old School Surgery, Bristol