Hypertension and my GA GA experience.

For almost three months I have been scratching my head wondering what has gone wrong with the treatment for high blood pressure of a patient. This is a 62 year old  female who speaks English fluently and dresses very smartly with a hijab ( head cover) and wearing long stockings. She has been my patient since 2009 and initially her blood pressure was well controlled with only one drug. In fact I complimented on her blood parameters which were excellent for someone her age. Both cholesterol and sugar level are normal.

However early this year her blood pressure has been climbing up necessitating another drug. As a doctor who have been treating many hypertensive patients, I noticed that it is better not to maximize the dose of only one drug to avoid unnecessary side effects. Instead patients seem to respond better if another class of anti-hypertensive drug is added to the regime. So that was what I did. Being overcautious I always ask patients whose drug regime I alter to return to the clinic after about two weeks or earlier should they experience some adverse effects.

Sphygmomanometer and Stethoscope - BP measuring set

This particular patient who I shall refer to as LP did not do either. Instead she claimed after taking the second drug she became dizzy and her blood pressure, according to her home electronic BP set was high (?). She immediately stopped the second drug and continued using the first drug for one month before she finally came to the clinic.

Her blood pressure was noted to be still high, needless to say and because she claimed she could not tolerate the second drug, I prescribed another class of anti-hypertensive and this time insisted that she should return to the clinic as instructed.

She returned after two weeks and her blood pressure was still high and yet she did not appear convinced with my measurement. Instead  she related how low her blood pressure was when she measured with her home BP set. She repeatedly claimed that she became dizzy when she took the extra drug. I was getting exasperated but tried my best to remain cool outwardly. Because despite the lowest dose of the additional drug prescribed, her blood pressure was still high during that consultation. I asked my nurse to use the clinic machine to measure and confirm her blood pressure, yes it was high, more than 140/90. I was at my wit's end then it dawned upon me that she might be taking something else at home that could have brought down her blood pressure more than clinically necessary.

Further friendly probing revealed that she had been taking a herbal concoction "PEGAGA" (Malay name for a plant) since early this year for her varicose vein. My! This was the first time that she admitted that she had varicose veins. This is the sort of problems facing you when you examine a woman covered from head to toe because you cannot really describe her general physical appearance to help you in your clinical examination. I asked her to show me her legs. She was hesitant despite me being a woman myself. When she at last took off her long stockings then I observed the multiple tortuous coarse veins running down the back of the knees to her calves. According to her the herb helped reduce her bilateral foot swelling on prolonged standing. You can go here http://thestar.com.my/health/story.asp?file=/2007/7/29/health/18419175&sec=health for the news report on the herb.

Pegaga ( Centella asiatica)

Well, if the plant's chemical can reduce tissue swelling due to abnormal veins ( may well be through an enzyme like prostaglandin) I surmise, for lack of any scientific evidence that it  could also interfere with or work in synergy with the drug I was prescribing to further lower her blood pressure causing her to feel faint and dizzy. It happens that she took the concoction in the afternoon whereas she saw me normally in the morning and her low blood pressure occurring usually in the  late afternoon and evening. Most likely the effect of this plant chemical is period-dependent and as the effect wears off, her high blood pressure returns!

I told LP she has to choose whether she wanted to be treated by a doctor or be on her own medication. I warned her that there was no way to monitor the effects of "agents" sold over the counter as herbal medicine as there was no proper research on them in terms of dosages and frequency of use as well as on the side effects and drug interactions. A doctor cannot possibly monitor a patient who uses other agents/drugs behind his/her back. I told her either she stop using the herb and take a clinic's medication for her varicose veins or she can continue taking the herb but see another doctor.

She decided to stop the herbal remedy and is now being monitored for the best combination of anti-hypertensive drugs for her rising blood pressure. I also advised LP not to throw away her home BP set as most likely the low blood pressure incidences would not recur with the stoppage of the herbs. So far so good and my own "ga ga " blood pressure is returning to normal now!